Healthcare Provider Details

I. General information

NPI: 1871763961
Provider Name (Legal Business Name): YARITZA MIRANDA-RIVERA D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LONG POND RD SUITE 115
GREECE NY
14626-1177
US

IV. Provider business mailing address

4453 CHESTNUT RIDGE RD APT. #1
AMHERST NY
14228-3246
US

V. Phone/Fax

Practice location:
  • Phone: 585-225-7790
  • Fax:
Mailing address:
  • Phone: 716-228-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number051791-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: