Provider Demographics
NPI:1306402524
Name:MIRACLE DENTAL CENTER
Entity Type:Organization
Organization Name:MIRACLE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FROLOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:267-882-7672
Mailing Address - Street 1:963 STREET RD # A
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4728
Mailing Address - Country:US
Mailing Address - Phone:267-990-8668
Mailing Address - Fax:
Practice Address - Street 1:963 STREET RD # A
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4728
Practice Address - Country:US
Practice Address - Phone:267-990-8668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty