Healthcare Provider Details

I. General information

NPI: 1598840407
Provider Name (Legal Business Name): ANN KHAZZANDRA MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4432 LAS POSITAS RD
LIVERMORE CA
94551-9529
US

IV. Provider business mailing address

2656 MELBOURNE WAY
SAN RAMON CA
94582-5768
US

V. Phone/Fax

Practice location:
  • Phone: 925-724-2422
  • Fax:
Mailing address:
  • Phone: 510-673-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: