1235264060 NPI number — EVELYN MIRANDA HALEM, DMD, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235264060 NPI number — EVELYN MIRANDA HALEM, DMD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVELYN MIRANDA HALEM, DMD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235264060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 S HIAWASSEE RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32835-5786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-294-6009
Provider Business Mailing Address Fax Number:
407-294-2722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 S HIAWASSEE RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-5786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-294-6009
Provider Business Practice Location Address Fax Number:
407-294-2722
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALEM
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
MIRANDA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-294-6009

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13516 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112334300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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