Provider Demographics
NPI:1932110491
Name:MIRANDA, MARIE C
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:C
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:C
Other - Last Name:JUANEZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:301 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-6921
Mailing Address - Country:US
Mailing Address - Phone:410-574-2454
Mailing Address - Fax:
Practice Address - Street 1:301 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-6921
Practice Address - Country:US
Practice Address - Phone:410-574-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice