Provider Demographics
NPI:1346393766
Name:MILLER, BRIAN KEITH (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:MILLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-2052
Mailing Address - Country:US
Mailing Address - Phone:251-867-5625
Mailing Address - Fax:251-867-5648
Practice Address - Street 1:420 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-2052
Practice Address - Country:US
Practice Address - Phone:251-867-5625
Practice Address - Fax:251-867-5648
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL90978OtherBLUE CROSS & BLUE SHIELD