=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235264060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVELYN MIRANDA HALEM, DMD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 03/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 S HIAWASSEE RD STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-294-6009
-----------------------------------------------------
Fax | 407-294-2722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 S HIAWASSEE RD STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-294-6009
-----------------------------------------------------
Fax | 407-294-2722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EVELYN MIRANDA HALEM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-294-6009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13516
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------