Provider Demographics
NPI:1396835609
Name:MILLER, DWAYNE EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:EDWARD
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 1:4450 WORTHINGTON CT
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-1161
Mailing Address - Country:US
Mailing Address - Phone:727-784-3228
Mailing Address - Fax:
Practice Address - Street 1:28913 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2407
Practice Address - Country:US
Practice Address - Phone:727-772-8772
Practice Address - Fax:727-772-9583
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00136621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071049102Medicaid