Healthcare Provider Details

I. General information

NPI: 1356955603
Provider Name (Legal Business Name): EURIS MIGUEL MIESES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 ENDURING FREEDOM DR
FORT DRUM NY
13602-5503
US

IV. Provider business mailing address

10590 ENDURING FREEDOM DR
FORT DRUM NY
13602-5503
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-5576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02805400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02805400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: