Provider Demographics
NPI:1508284837
Name:RANDALL L MILLER DDS LLC
Entity Type:Organization
Organization Name:RANDALL L MILLER DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-398-2103
Mailing Address - Street 1:117 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1245
Mailing Address - Country:US
Mailing Address - Phone:317-398-2103
Mailing Address - Fax:317-421-1570
Practice Address - Street 1:117 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1245
Practice Address - Country:US
Practice Address - Phone:317-398-2103
Practice Address - Fax:317-421-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009483A122300000X
IN12010992A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100224820AMedicaid