Provider Demographics
NPI:1760488514
Name:MILLER, COLETTA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLETTA
Middle Name:M
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 1:3740 E LAKE CTR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5805
Mailing Address - Country:US
Mailing Address - Phone:217-224-6789
Mailing Address - Fax:217-224-9675
Practice Address - Street 1:3740 E LAKE CTR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5805
Practice Address - Country:US
Practice Address - Phone:217-224-6789
Practice Address - Fax:217-224-9675
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0013831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0589937Medicaid
IL102687Medicaid
IA0589937Medicaid
IL102687Medicaid