Provider Demographics
NPI:1538469598
Name:CHARLES N. MILLER DDS PA
Entity Type:Organization
Organization Name:CHARLES N. MILLER DDS PA
Other - Org Name:DISTINCTIVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:N
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-332-8888
Mailing Address - Street 1:417 LINCOLN AVE NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-4952
Mailing Address - Country:US
Mailing Address - Phone:507-332-8888
Mailing Address - Fax:
Practice Address - Street 1:417 LINCOLN AVE NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4952
Practice Address - Country:US
Practice Address - Phone:507-332-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND107381223G0001X
MND72551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty