Provider Demographics
NPI:1669488730
Name:MIRAKIAN, ROSANNE V (DDS)
Entity type:Individual
Prefix:DR
First Name:ROSANNE
Middle Name:V
Last Name:MIRAKIAN
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:PO BOX 52225
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-7225
Mailing Address - Country:US
Mailing Address - Phone:215-880-5135
Mailing Address - Fax:
Practice Address - Street 1:600 PEMBERTON BROWNS MILLS ROAD
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08060
Practice Address - Country:US
Practice Address - Phone:609-894-1213
Practice Address - Fax:609-894-1219
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22619001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0099490Medicaid