Provider Demographics
NPI:1982605168
Name:MORENO, MIRALDA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRALDA
Middle Name:G
Last Name:MORENO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 STATE AVE
Mailing Address - Street 2:SUITE 375
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66101-2516
Mailing Address - Country:US
Mailing Address - Phone:913-647-1900
Mailing Address - Fax:913-647-1901
Practice Address - Street 1:753 STATE AVE
Practice Address - Street 2:SUITE 375
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66101-2516
Practice Address - Country:US
Practice Address - Phone:913-647-1900
Practice Address - Fax:913-647-1901
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60041122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist