Provider Demographics
NPI:1811727605
Name:MILLER, REBECCA GWENDOLYN (DMD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GWENDOLYN
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 1:874 NEEDMORE RD APT P4
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-2346
Mailing Address - Country:US
Mailing Address - Phone:540-931-8453
Mailing Address - Fax:
Practice Address - Street 1:6145 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5558
Practice Address - Country:US
Practice Address - Phone:270-412-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist