Provider Demographics
NPI:1306861638
Name:MILLEA, JOHN DAVID
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MILLEA
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 1:3470 PARKER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-543-4022
Mailing Address - Fax:
Practice Address - Street 1:3470 PARKER BOULEVARD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-543-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-91761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice