Provider Demographics
NPI:1609055151
Name:MILLER, TIMOTHY J (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W VIENNA ST
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-1333
Mailing Address - Country:US
Mailing Address - Phone:810-687-9700
Mailing Address - Fax:
Practice Address - Street 1:145 W VIENNA ST
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-1333
Practice Address - Country:US
Practice Address - Phone:810-687-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0613861223G0001X
MI44184801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4418480Medicaid