Provider Demographics
NPI:1184312977
Name:ATTALLA, MIRETTE
Entity type:Individual
Prefix:
First Name:MIRETTE
Middle Name:
Last Name:ATTALLA
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 1:10431 SLATER AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7706
Mailing Address - Country:US
Mailing Address - Phone:424-361-8431
Mailing Address - Fax:
Practice Address - Street 1:10431 SLATER AVE APT 204
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7706
Practice Address - Country:US
Practice Address - Phone:424-361-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS109258122300000X, 1223G0001X
390200000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice