Provider Demographics
NPI:1467650481
Name:MILLAN, JEROME L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:L
Last Name:MILLAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 SOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2252
Mailing Address - Country:US
Mailing Address - Phone:215-742-2233
Mailing Address - Fax:
Practice Address - Street 1:1517 SOLLY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2252
Practice Address - Country:US
Practice Address - Phone:215-742-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021676L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist