Provider Demographics
NPI:1376605709
Name:MILLER, GERALD O (DDS)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:O
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:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535
Mailing Address - Country:US
Mailing Address - Phone:435-587-2528
Mailing Address - Fax:435-587-3585
Practice Address - Street 1:217 S 100 W
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535
Practice Address - Country:US
Practice Address - Phone:435-587-2528
Practice Address - Fax:435-587-3585
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1393109922122300000X
UT1393108903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
139310Medicare UPIN