Provider Demographics
NPI:1528299948
Name:MIRABAL, ROXANA (DMD)
Entity type:Individual
Prefix:DR
First Name:ROXANA
Middle Name:
Last Name:MIRABAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W. COWLES ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5926
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:
Practice Address - Street 1:1717 WEST COWLES ST.
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:706-255-2879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO13951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist