Provider Demographics
NPI:1598840407
Name:MIRANDA, ANN KHAZZANDRA
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:KHAZZANDRA
Last Name:MIRANDA
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 1:2656 MELBOURNE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5768
Mailing Address - Country:US
Mailing Address - Phone:510-673-6707
Mailing Address - Fax:
Practice Address - Street 1:4432 LAS POSITAS RD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-9529
Practice Address - Country:US
Practice Address - Phone:925-724-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist