Provider Demographics
NPI:1629197843
Name:MILLER, CONNIE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:A
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 1:675 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-4962
Mailing Address - Country:US
Mailing Address - Phone:319-377-9877
Mailing Address - Fax:319-377-4558
Practice Address - Street 1:675 S 11TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-4962
Practice Address - Country:US
Practice Address - Phone:319-377-9877
Practice Address - Fax:319-377-4558
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26103OtherWELLMARK BLUEDENTAL
IA0048744Medicaid
IA606496OtherUNITED CONCORDICE