Provider Demographics
NPI:1700090669
Name:MIRANDA, JOSE MANUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MANUEL
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2TR510 VIA ADELINA
Mailing Address - Street 2:VILLA FONTANA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-3864
Mailing Address - Country:US
Mailing Address - Phone:787-762-0045
Mailing Address - Fax:
Practice Address - Street 1:2TR510 VIA ADELINA
Practice Address - Street 2:VILLA FONTANA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-3864
Practice Address - Country:US
Practice Address - Phone:787-762-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice