Provider Demographics
NPI:1972350395
Name:MORAN, MINERVA MARIA
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:MARIA
Last Name:MORAN
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 1:1001 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4124
Mailing Address - Country:US
Mailing Address - Phone:702-583-2773
Mailing Address - Fax:
Practice Address - Street 1:9033 ELMHURST AVE FL 3
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7935
Practice Address - Country:US
Practice Address - Phone:718-505-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty