Provider Demographics
NPI:1114006541
Name:MILLER, JAN S
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:S
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 BELLE TERRE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1935
Mailing Address - Country:US
Mailing Address - Phone:631-743-9090
Mailing Address - Fax:631-743-9091
Practice Address - Street 1:635 BELLE TERRE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1935
Practice Address - Country:US
Practice Address - Phone:631-743-9090
Practice Address - Fax:631-743-9091
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice