Individual
MIRIAM KEROLUS FANOUSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
34 MOUNTAIN BLVD, WARREN, NJ 07059-2640
(347) 307-1381
Mailing address
46 BARTLETT AVE, STATEN ISLAND, NY 10312-2462
(347) 307-1381
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
22DI02942100
NJ
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/16/2014
Last updated
03/05/2025
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