Provider Demographics
NPI:1720347859
Name:MILLER, MATTHEW JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JON
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 1:940 ROANOKE AVE
Mailing Address - Street 2:NORTH FORK ORTHODONTICS
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-727-4040
Mailing Address - Fax:
Practice Address - Street 1:940 ROANOKE AVE
Practice Address - Street 2:NORTH FORK ORTHODONTICS
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-727-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0577381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04588065Medicaid