Provider Demographics
NPI:1134616394
Name:MIRANDA, JASON DEREK (RDA/OAP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DEREK
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:RDA/OAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5033 W AVENUE L10 APT 15
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-3681
Mailing Address - Country:US
Mailing Address - Phone:661-709-0637
Mailing Address - Fax:
Practice Address - Street 1:5033 W AVENUE L10 APT 15
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-3681
Practice Address - Country:US
Practice Address - Phone:661-709-0637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA84892126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant