Provider Demographics
NPI:1831884436
Name:ANDERSON, MIRANDA LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 W DOMAINE CT
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-1001
Mailing Address - Country:US
Mailing Address - Phone:208-818-2820
Mailing Address - Fax:
Practice Address - Street 1:516 N EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0852
Practice Address - Country:US
Practice Address - Phone:509-928-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5521122300000X
390200000X
WADE61604888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program