Provider Demographics
NPI:1932663416
Name:PETER, MIRANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:PETER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W CLAIREMONT AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6223
Mailing Address - Country:US
Mailing Address - Phone:715-833-6271
Mailing Address - Fax:
Practice Address - Street 1:N56W14044 SILVER SPRING DR # 101
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-5933
Practice Address - Country:US
Practice Address - Phone:262-373-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001831-15122300000X
WI10018311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist