Provider Demographics
NPI:1669757670
Name:MIRANDA, MALATHI SHIRLEY (BDS, CAGS, MSCD)
Entity type:Individual
Prefix:DR
First Name:MALATHI
Middle Name:SHIRLEY
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:BDS, CAGS, MSCD
Other - Prefix:DR
Other - First Name:MALATHI
Other - Middle Name:SHIRLEY
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3302 GASTON AVE
Mailing Address - Street 2:# 711
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2013
Mailing Address - Country:US
Mailing Address - Phone:214-828-8446
Mailing Address - Fax:214-874-4555
Practice Address - Street 1:3302 GASTON AVE
Practice Address - Street 2:# 711
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2013
Practice Address - Country:US
Practice Address - Phone:214-828-8446
Practice Address - Fax:214-874-4555
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF-254461223D0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223P0221XDental ProvidersDentistPediatric Dentistry