Basic Information
| Provider Information | |||||||||
| NPI: | 1225055940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRIYALA | ||||||||
| FirstName: | VINOD | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS, BDS, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405324858 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1408 CAMPBELL DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405349231 | ||||||||
| FaxNumber: | 7405349378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 30-023190 | OH | Y | Dental Providers | Dentist | Pediatric Dentistry | 122300000X | 2901019042 | MI | N | Dental Providers | Dentist | 122300000X | 30-023190 | OH | N | Dental Providers | Dentist | 122300000X | 3894 | WV | N | Dental Providers | Dentist | 1223P0221X | 34 | WV | N | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 3057883 | 05 | OH | MEDICAID | 3810018398 | 05 | WV | MEDICAID | 7100236110 | 05 | KY | MEDICAID |