Provider Demographics
NPI:1306866553
Name:MILLER, ROGER K (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:K
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 PLAZA DR.
Mailing Address - Street 2:P.O. BOX 638
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086
Mailing Address - Country:US
Mailing Address - Phone:704-739-7956
Mailing Address - Fax:704-739-1659
Practice Address - Street 1:1303 PLAZA DR.
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086
Practice Address - Country:US
Practice Address - Phone:704-739-7956
Practice Address - Fax:704-739-1659
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7995963Medicaid
NCBCBSOF NCOther95963