Provider Demographics
NPI:1114944675
Name:MIRANDA, JUAN RAMON
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:RAMON
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
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 21107
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1107
Mailing Address - Country:US
Mailing Address - Phone:787-765-5106
Mailing Address - Fax:787-751-5626
Practice Address - Street 1:71 CALLE ARZUAGA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-3703
Practice Address - Country:US
Practice Address - Phone:787-765-5106
Practice Address - Fax:787-751-5626
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist