Provider Demographics
NPI:1609234426
Name:MILLER, MARIA (RDH)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N. JEFFERSON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N. JEFFERSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-781-0952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011392124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-3387719OtherTHE FOUNTAIN CLINIC