Provider Demographics
NPI:1598887309
Name:MIERISCH, OTTO SR (DN13254)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:
Last Name:MIERISCH
Suffix:SR
Gender:M
Credentials:DN13254
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13965 SW 42ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3641
Mailing Address - Country:US
Mailing Address - Phone:305-551-1041
Mailing Address - Fax:305-228-7332
Practice Address - Street 1:477 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3041
Practice Address - Country:US
Practice Address - Phone:305-541-8884
Practice Address - Fax:305-541-8830
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14290OtherATLANTIC DENTAL INC.