Provider Demographics
NPI:1790212785
Name:MILLER, CHARLES BRIGHAM
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRIGHAM
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12523 S PASTURE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-4841
Mailing Address - Country:US
Mailing Address - Phone:801-900-8686
Mailing Address - Fax:
Practice Address - Street 1:12523 S PASTURE RD STE 150
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-4841
Practice Address - Country:US
Practice Address - Phone:801-900-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT951008299241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty