Provider Demographics
NPI:1790811180
Name:MILLER, GREGORY PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
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 1:1140 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-3533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-3533
Practice Address - Country:US
Practice Address - Phone:507-345-5464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND92181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND9218OtherSTATE DENTAL LICENSE