Provider Demographics
NPI:1083990857
Name:CARLILE, MIRANDA ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ANN
Last Name:CARLILE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1189
Practice Address - Country:US
Practice Address - Phone:575-746-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3530124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist