Provider Demographics
NPI:1417026097
Name:MILLER, CLINTON (DDS, PA-C)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS, PA-C
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 368
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0368
Mailing Address - Country:US
Mailing Address - Phone:360-491-8439
Mailing Address - Fax:360-491-6328
Practice Address - Street 1:615 LILLY RD NE STE 100
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5117
Practice Address - Country:US
Practice Address - Phone:360-491-4211
Practice Address - Fax:360-493-0407
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310031223G0001X
TXPA05405363A00000X
WAPA10004850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1009815Medicaid
WAP53193Medicare UPIN
TX8K0427Medicare PIN
TX842831OtherBLUE CROSS BLUE SHIELD TX