Provider Demographics
NPI:1689385775
Name:SCANLON, MIRA GIULIETTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:GIULIETTA
Last Name:SCANLON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MIRA
Other - Middle Name:GIULIETTA
Other - Last Name:GOTTARDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3429 EDGEHILL DR APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3640
Mailing Address - Country:US
Mailing Address - Phone:336-500-4786
Mailing Address - Fax:
Practice Address - Street 1:3429 EDGEHILL DR APT 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-3640
Practice Address - Country:US
Practice Address - Phone:336-500-4786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108495122300000X
CA108405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty