Provider Demographics
NPI:1558733030
Name:VALENZUELA, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:VALENZUELA
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:PO BOX 1101
Mailing Address - Street 2:
Mailing Address - City:ORACLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85623-1101
Mailing Address - Country:US
Mailing Address - Phone:520-603-8853
Mailing Address - Fax:
Practice Address - Street 1:13395 N MARANA MAIN ST
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-616-6200
Practice Address - Fax:520-682-1087
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH05961124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist