Provider Demographics
NPI:1043325145
Name:CHILDS, MIRANDA MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:MICHELLE
Last Name:CHILDS
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 1:312 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5315
Mailing Address - Country:US
Mailing Address - Phone:870-245-2323
Mailing Address - Fax:270-245-2368
Practice Address - Street 1:312 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE D
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5315
Practice Address - Country:US
Practice Address - Phone:870-245-2323
Practice Address - Fax:270-245-2368
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U242OtherBLUE CROSS BLUE SHIELD PR
AR766360OtherUNITED CONCORDIA