Provider Demographics
NPI:1306229703
Name:MICHAEL J. MILLER, DMD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL J. MILLER, DMD, A PROFESSIONAL CORPORATION
Other - Org Name:TIERRASANTA PLAZA DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN DYKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-278-6444
Mailing Address - Street 1:10715 TIERRASANTA BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2610
Mailing Address - Country:US
Mailing Address - Phone:858-278-6444
Mailing Address - Fax:828-279-6444
Practice Address - Street 1:10715 TIERRASANTA BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2610
Practice Address - Country:US
Practice Address - Phone:858-278-6444
Practice Address - Fax:828-279-6444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty