Provider Demographics
NPI:1245319151
Name:MIRISE, PHILIP JAMES (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JAMES
Last Name:MIRISE
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 1:850 CEDAR LANE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-1089
Mailing Address - Country:US
Mailing Address - Phone:317-736-7476
Mailing Address - Fax:317-736-1946
Practice Address - Street 1:850 CEDAR LANE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-1089
Practice Address - Country:US
Practice Address - Phone:317-736-7476
Practice Address - Fax:317-736-1946
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200189530AMedicaid
IN231240Medicare ID - Type Unspecified
V06164Medicare UPIN