Provider Demographics
NPI:1467943019
Name:MILLER, MARY LABORDE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LABORDE
Last Name:MILLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 SHELL BEACH DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5825
Mailing Address - Country:US
Mailing Address - Phone:337-377-6020
Mailing Address - Fax:
Practice Address - Street 1:2425 33RD AVE W
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3255
Practice Address - Country:US
Practice Address - Phone:206-283-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68561223G0001X
WA60949816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice