MEDICARE: DR. DAVID J. MIRANDA D.D.S.

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	122300000X	Dentist	5149	TN

General Provider Information

NPI Number	:	1639290364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID J. MIRANDA D.D.S.

Provider Business Mailing 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	:

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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