Healthcare Provider Details

I. General information

NPI: 1982162657
Provider Name (Legal Business Name): SANDRA MIRANDA DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1388 S NAVAJO ST
SALT LAKE CITY UT
84104-3493
US

IV. Provider business mailing address

2621 S 3270 W
WEST VALLEY CITY UT
84119-1119
US

V. Phone/Fax

Practice location:
  • Phone: 19-552-3608
  • Fax: 801-746-0420
Mailing address:
  • Phone: 385-261-2737
  • Fax: 17-460-4208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6781179-0701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: