Provider Demographics
NPI:1760548614
Name:MILLER, THOMAS J (DDS)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
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 1:2805 LIBAL ST.
Mailing Address - Street 2:STE. C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2877
Mailing Address - Country:US
Mailing Address - Phone:920-339-8980
Mailing Address - Fax:920-339-0133
Practice Address - Street 1:2805 LIBAL ST.
Practice Address - Street 2:STE. C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2877
Practice Address - Country:US
Practice Address - Phone:920-339-8980
Practice Address - Fax:920-339-0133
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33708700Medicaid