Provider Demographics
NPI:1003896697
Name:MCMILLEN, FREDRICK H (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:H
Last Name:MCMILLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 HARTFORD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919
Mailing Address - Country:US
Mailing Address - Phone:401-331-7171
Mailing Address - Fax:401-331-2527
Practice Address - Street 1:1226 HARTFORD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:401-331-7171
Practice Address - Fax:401-331-2527
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:2006-10-02
Deactivation Code:
Reactivation Date:2007-06-22
Provider Licenses
StateLicense IDTaxonomies
RIDENO14791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1479OtherDELTA DENTAL
RI89292OtherBLUE CROSS
RIFM00711Medicaid