Provider Demographics
NPI:1104173517
Name:HAEFELE, MIRANDA ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:ANN
Last Name:HAEFELE
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 1:2546 E 2ND ST
Mailing Address - Street 2:#300
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2062
Mailing Address - Country:US
Mailing Address - Phone:307-259-9286
Mailing Address - Fax:
Practice Address - Street 1:2546 E 2ND ST
Practice Address - Street 2:#300
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2062
Practice Address - Country:US
Practice Address - Phone:307-259-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice