Provider Demographics
NPI:1750058806
Name:MILLER, JERRY SIDNEY (DDS)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:SIDNEY
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 1:9298 STATE HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3486
Mailing Address - Country:US
Mailing Address - Phone:315-393-3143
Mailing Address - Fax:
Practice Address - Street 1:1110 TIBBITS DRIVE
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-393-8400
Practice Address - Fax:315-393-0167
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043376-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty