Provider Demographics
NPI:1811257827
Name:SAN MIGUEL, LORRAINE (RDH)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8519 COLLINGWOOD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148
Mailing Address - Country:US
Mailing Address - Phone:210-412-5798
Mailing Address - Fax:210-855-2565
Practice Address - Street 1:8519 COLLINGWOOD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-2849
Practice Address - Country:US
Practice Address - Phone:210-412-5798
Practice Address - Fax:210-855-2565
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906556124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist