Provider Demographics
NPI:1528407517
Name:MILLER, JASON LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LEE
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 1:8357 SALMONBERRY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5078
Mailing Address - Country:US
Mailing Address - Phone:208-251-5309
Mailing Address - Fax:
Practice Address - Street 1:10621 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4260
Practice Address - Country:US
Practice Address - Phone:208-251-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9684122300000X
AZ9651122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist