Provider Demographics
NPI:1609013234
Name:MIRANDA, PASTOR ALFREDO
Entity Type:Individual
Prefix:MR
First Name:PASTOR
Middle Name:ALFREDO
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SAN MANCOS ST.#M
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 SAN MARCOS ST.#M
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776
Practice Address - Country:US
Practice Address - Phone:213-840-7496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44060126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant