Provider Demographics
NPI:1942426275
Name:SMITH, MIRANDA WHYLLY (DDS)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:WHYLLY
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RHONDA
Other - Last Name:WHYLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1214 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609
Mailing Address - Country:US
Mailing Address - Phone:352-397-2139
Mailing Address - Fax:352-397-2192
Practice Address - Street 1:2707 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3312
Practice Address - Country:US
Practice Address - Phone:727-785-6521
Practice Address - Fax:727-785-6237
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075275400Medicaid