Provider Demographics
NPI:1508638495
Name:FIDAL, MIRIAM MIKHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:MIKHAEL
Last Name:FIDAL
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 1:30 VIA CORALLE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1614
Mailing Address - Country:US
Mailing Address - Phone:714-580-3041
Mailing Address - Fax:
Practice Address - Street 1:34880 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4235
Practice Address - Country:US
Practice Address - Phone:909-797-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1095571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice