Provider Demographics
NPI:1427209329
Name:MILLER, MARK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
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 1:307 N 300 W STE 304
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1852
Mailing Address - Country:US
Mailing Address - Phone:801-544-4003
Mailing Address - Fax:
Practice Address - Street 1:307 N 300 W STE 304
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1852
Practice Address - Country:US
Practice Address - Phone:801-544-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT99-375792-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN870623840-00001OtherDELTA DENTAL