Provider Demographics
NPI:1184752099
Name:MILLER, MATTHEW EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
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 1:1905 SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1048
Mailing Address - Country:US
Mailing Address - Phone:641-236-0096
Mailing Address - Fax:
Practice Address - Street 1:825 BROAD ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2153
Practice Address - Country:US
Practice Address - Phone:641-236-6169
Practice Address - Fax:641-236-6041
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice