Provider Demographics
NPI:1396983961
Name:MIRANDA, DAVID ELLMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ELLMAN
Last Name:MIRANDA
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 1:3997 BECKLEY RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-7660
Mailing Address - Country:US
Mailing Address - Phone:304-431-5499
Mailing Address - Fax:304-431-3400
Practice Address - Street 1:3997 BECKLEY RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-7660
Practice Address - Country:US
Practice Address - Phone:304-431-5499
Practice Address - Fax:304-431-3400
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV3097122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001735593OtherBCBS
WV0133749000Medicaid