Provider Demographics
NPI:1093021305
Name:MILLER, MATTHEW JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:MILLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 BAINBRIDGE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 HAVERFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1361
Practice Address - Country:US
Practice Address - Phone:215-685-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0383881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice