Provider Demographics
NPI:1326188939
Name:MILLER, MARTIN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-3100
Mailing Address - Country:US
Mailing Address - Phone:516-626-1663
Mailing Address - Fax:516-626-1667
Practice Address - Street 1:153 DYCKMAN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1003
Practice Address - Country:US
Practice Address - Phone:212-569-5300
Practice Address - Fax:212-544-0435
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00280153Medicaid