Provider Demographics
NPI:1518966423
Name:MILLER, MARK A (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MILLER
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-0220
Mailing Address - Country:US
Mailing Address - Phone:503-852-7147
Mailing Address - Fax:503-852-7419
Practice Address - Street 1:133 E MAIN
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:OR
Practice Address - Zip Code:97111
Practice Address - Country:US
Practice Address - Phone:503-852-7147
Practice Address - Fax:503-852-7149
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
OR55131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075390Medicaid