Provider Demographics
NPI:1376606434
Name:MILLER, KENNETH W
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 SMITHVILLE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7803
Mailing Address - Country:US
Mailing Address - Phone:478-971-4799
Mailing Address - Fax:
Practice Address - Street 1:245 SMITHVILLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7803
Practice Address - Country:US
Practice Address - Phone:478-971-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0091811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice