Provider Demographics
NPI:1255419305
Name:MILLER, KENNETH GORDON (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GORDON
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 1:233 NORTHERN BLVD
Mailing Address - Street 2:STE 5
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8720
Mailing Address - Country:US
Mailing Address - Phone:570-954-8211
Mailing Address - Fax:
Practice Address - Street 1:233 NORTHERN BLVD
Practice Address - Street 2:STE 5
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-8720
Practice Address - Country:US
Practice Address - Phone:570-586-5300
Practice Address - Fax:570-586-4720
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA021625L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00905525Medicaid
PA00905525Medicaid
T71993Medicare UPIN