Provider Demographics
NPI:1689987083
Name:MILLARD, GARRY DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:DEAN
Last Name:MILLARD
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 1:1905 BLAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4288
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:BUILDING C
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4700
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000103511223G0001X
CA419591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57402086Medicaid