Provider Demographics
NPI:1043566672
Name:GAVIN J. MILLER, DDS, INC.
Entity Type:Organization
Organization Name:GAVIN J. MILLER, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-546-7667
Mailing Address - Street 1:4130 LA JOLLA VILLAGE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1480
Mailing Address - Country:US
Mailing Address - Phone:858-546-7667
Mailing Address - Fax:858-546-7693
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR STE 205
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1480
Practice Address - Country:US
Practice Address - Phone:858-546-7667
Practice Address - Fax:858-546-7693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA423671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty