Provider Demographics
NPI:1164993663
Name:HALCOMB, MIRANDA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:HALCOMB
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 1:10438 N COUNTY ROAD 17
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-8785
Mailing Address - Country:US
Mailing Address - Phone:970-629-9728
Mailing Address - Fax:
Practice Address - Street 1:1550 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-7915
Practice Address - Country:US
Practice Address - Phone:970-686-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906303124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist