Provider Demographics
NPI:1164059663
Name:MIRANDA, KRISTINA MICHELLE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MICHELLE
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 HOLSONBACK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5114
Mailing Address - Country:US
Mailing Address - Phone:386-274-0500
Mailing Address - Fax:
Practice Address - Street 1:1845 HOLSONBACK DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5114
Practice Address - Country:US
Practice Address - Phone:386-274-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH17321124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist