Provider Demographics
NPI:1740362839
Name:MILLER, MATTHEW IVAN
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:IVAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2947
Mailing Address - Country:US
Mailing Address - Phone:317-894-3400
Mailing Address - Fax:317-894-3475
Practice Address - Street 1:11701 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2947
Practice Address - Country:US
Practice Address - Phone:317-894-3400
Practice Address - Fax:317-894-3475
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist