Provider Demographics
NPI:1437289436
Name:MILLER, JOHN JR (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MILLER
Suffix:JR
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 3996
Mailing Address - Street 2:200 EAST BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-3996
Mailing Address - Country:US
Mailing Address - Phone:307-733-4021
Mailing Address - Fax:
Practice Address - Street 1:200 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-3996
Practice Address - Country:US
Practice Address - Phone:307-733-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYT787794Medicare UPIN