Provider Demographics
NPI:1568517183
Name:MILLER, GAVIN JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:JACOB
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 1:4130 LA JOLLA VILLAGE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1480
Mailing Address - Country:US
Mailing Address - Phone:858-546-7667
Mailing Address - Fax:858-546-7693
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR STE 205
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1480
Practice Address - Country:US
Practice Address - Phone:858-546-7667
Practice Address - Fax:858-546-7693
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA423671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice