Provider Demographics
NPI:1154447746
Name:ACOSTA, MIRIAM R (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:R
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21085 LAURETTA DR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-1655
Mailing Address - Country:US
Mailing Address - Phone:408-253-2296
Mailing Address - Fax:408-873-1215
Practice Address - Street 1:19286 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2504
Practice Address - Country:US
Practice Address - Phone:408-253-2296
Practice Address - Fax:408-873-1215
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA355851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice