Provider Demographics
NPI:1508755885
Name:SAN MIGUEL, EMALYN SAMALIO
Entity type:Individual
Prefix:
First Name:EMALYN
Middle Name:SAMALIO
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BURNT HICKORY CONNECTOR SW APT 434
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-5986
Mailing Address - Country:US
Mailing Address - Phone:423-244-4293
Mailing Address - Fax:
Practice Address - Street 1:113 PLANTATION AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2371
Practice Address - Country:US
Practice Address - Phone:770-748-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist