Provider Demographics
NPI:1356610398
Name:MILLER, GREGORY ALLEN (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
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 1:843 REED ST
Mailing Address - Street 2:P.O. BOX 189
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-1336
Mailing Address - Country:US
Mailing Address - Phone:208-226-2976
Mailing Address - Fax:208-226-1068
Practice Address - Street 1:843 REED ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1336
Practice Address - Country:US
Practice Address - Phone:208-226-2976
Practice Address - Fax:208-226-1068
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD20381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice