Provider Demographics
NPI:1740393636
Name:MILLER, MICHAEL JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
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 1:86A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2733
Mailing Address - Country:US
Mailing Address - Phone:304-472-8598
Mailing Address - Fax:304-472-0651
Practice Address - Street 1:86A E MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2733
Practice Address - Country:US
Practice Address - Phone:304-472-8598
Practice Address - Fax:304-472-0651
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136763000Medicaid