Provider Demographics
NPI:1700587409
Name:MILLER, JACKLYN (DMD)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 E 319TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-3662
Mailing Address - Country:US
Mailing Address - Phone:724-561-4321
Mailing Address - Fax:
Practice Address - Street 1:5135 PEARSON RD BLDG 10
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433-5346
Practice Address - Country:US
Practice Address - Phone:937-522-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty