Provider Demographics
NPI:1750434221
Name:MILLER, JOHN A (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2853
Mailing Address - Country:US
Mailing Address - Phone:843-546-5555
Mailing Address - Fax:843-546-7777
Practice Address - Street 1:1209 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2853
Practice Address - Country:US
Practice Address - Phone:843-546-5555
Practice Address - Fax:843-546-7777
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ29425Medicaid