Provider Demographics
NPI:1922198118
Name:MILLER, GLENN A (DDSMS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDSMS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10200 WEST MAIN STREET
Mailing Address - Street 2:SIGNAL HILL MEDICAL BUILDING
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-1495
Mailing Address - Country:US
Mailing Address - Phone:618-397-2464
Mailing Address - Fax:618-398-4450
Practice Address - Street 1:10200 WEST MAIN STREET
Practice Address - Street 2:SIGNAL HILL MEDICAL BUILDING
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-1495
Practice Address - Country:US
Practice Address - Phone:618-397-2464
Practice Address - Fax:618-398-4450
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A13884204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80115934OtherILLINOIS BLUE SHIELD
679927OtherUNITED CONCORDIA
T37949Medicare UPIN
679927OtherUNITED CONCORDIA