Healthcare Provider Details

I. General information

NPI: 1134616394
Provider Name (Legal Business Name): JASON DEREK MIRANDA RDA/OAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5033 W AVENUE L10 APT 15
LANCASTER CA
93536-3681
US

IV. Provider business mailing address

5033 W AVENUE L10 APT 15
LANCASTER CA
93536-3681
US

V. Phone/Fax

Practice location:
  • Phone: 661-709-0637
  • Fax:
Mailing address:
  • Phone: 661-709-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA84892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: