Provider Demographics
NPI:1326198433
Name:MILLER, NICHOLE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 RIDGEWAY DR
Mailing Address - Street 2:STE 4
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2023
Mailing Address - Country:US
Mailing Address - Phone:319-626-2119
Mailing Address - Fax:319-626-2315
Practice Address - Street 1:3290 RIDGEWAY DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-626-2119
Practice Address - Fax:319-626-2315
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0210906Medicaid