Provider Demographics
NPI:1982162657
Name:MIRANDA, SANDRA (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 S 3270 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1119
Mailing Address - Country:US
Mailing Address - Phone:385-261-2737
Mailing Address - Fax:017-460-4208
Practice Address - Street 1:1388 S NAVAJO ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3493
Practice Address - Country:US
Practice Address - Phone:019-552-3608
Practice Address - Fax:801-746-0420
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6781179-0701124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist