Healthcare Provider Details

I. General information

NPI: 1497675474
Provider Name (Legal Business Name): MIRANDA BROOKS RDH, CHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 CLANTON AVE
TAMPA FL
33603-1704
US

IV. Provider business mailing address

910 CLANTON AVE
TAMPA FL
33603-1704
US

V. Phone/Fax

Practice location:
  • Phone: 413-530-5591
  • Fax:
Mailing address:
  • Phone: 413-530-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number29322
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: