Provider Demographics
NPI:1255408548
Name:MILES, JERRY A (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:MILES
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 1:26317 W WASHINGTON STREET
Mailing Address - Street 2:P.O. BOX 4030
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2727
Mailing Address - Country:US
Mailing Address - Phone:804-524-7257
Mailing Address - Fax:804-524-6496
Practice Address - Street 1:26317 W WASHINGTON STREET
Practice Address - Street 2:BUILDING 110
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-524-7257
Practice Address - Fax:804-524-6496
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist