Provider Demographics
NPI:1578668349
Name:MIRRA, RICHARD M (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:MIRRA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:24 MAPLE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570
Mailing Address - Country:US
Mailing Address - Phone:516-766-0580
Mailing Address - Fax:516-766-6755
Practice Address - Street 1:24 MAPLE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-766-0580
Practice Address - Fax:516-766-6755
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0498911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery