Provider Demographics
NPI:1215041389
Name:MILLER, CHARLES B (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
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 1:200 S ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:PA
Mailing Address - Zip Code:16137
Mailing Address - Country:US
Mailing Address - Phone:724-622-3833
Mailing Address - Fax:724-662-1308
Practice Address - Street 1:200 S ERIE ST
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137
Practice Address - Country:US
Practice Address - Phone:724-622-3833
Practice Address - Fax:724-662-1308
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020421 L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005194020001Medicaid
PA039953OtherUNITED CONCORDIA