Provider Demographics
NPI:1497821854
Name:MIRON, DIEGO E (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:E
Last Name:MIRON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SOUTHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2526
Mailing Address - Country:US
Mailing Address - Phone:518-445-2505
Mailing Address - Fax:518-445-2508
Practice Address - Street 1:7 SOUTHWOODS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2526
Practice Address - Country:US
Practice Address - Phone:518-445-2505
Practice Address - Fax:518-445-2508
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052080-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10115921OtherCDPHP
NY02703166Medicaid
NYV11559Medicare UPIN
NY02703166Medicaid