Provider Demographics
NPI:1740409820
Name:MIRABILE, JASON DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DANIEL
Last Name:MIRABILE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 15TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1812
Mailing Address - Country:US
Mailing Address - Phone:310-319-9300
Mailing Address - Fax:310-319-9320
Practice Address - Street 1:1304 15TH ST STE 305
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1812
Practice Address - Country:US
Practice Address - Phone:310-319-9300
Practice Address - Fax:310-319-9320
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49147122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist