Provider Demographics
NPI:1871853739
Name:MILLER, NICHOLAS G (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:G
Last Name:MILLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2160
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0908
Mailing Address - Country:US
Mailing Address - Phone:208-263-7101
Mailing Address - Fax:208-263-7198
Practice Address - Street 1:30410 HIGHWAY 200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9601
Practice Address - Country:US
Practice Address - Phone:208-263-7101
Practice Address - Fax:208-263-7198
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-44861223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health