MEDICARE: BANYAS MIRANDA DENTISTRY GPS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1083352165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANYAS MIRANDA DENTISTRY GPS PLLC

Provider Business Mailing Address
First Line	:	100 E HUNTINGTON AVE STE E
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-2900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	216 W WATAUGA AVE
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-5624
Country	:	US
Telephone Number	:	423-928-0265
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	WILLIAM LITTLE
Credential	:	DDS
Telephone Number	:	870-243-4406

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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