Provider Demographics
NPI:1215572276
Name:MILLER DENTAL GROUP POOLER LLC
Entity Type:Organization
Organization Name:MILLER DENTAL GROUP POOLER LLC
Other - Org Name:MILLER DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-330-6000
Mailing Address - Street 1:103 PARK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4262
Mailing Address - Country:US
Mailing Address - Phone:912-330-6000
Mailing Address - Fax:
Practice Address - Street 1:103 PARK AVE STE 200
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4262
Practice Address - Country:US
Practice Address - Phone:912-330-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-14
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122400000XDental ProvidersDenturistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538518774OtherNPPES
1578782702OtherNPPES