Provider Demographics
NPI:1831187822
Name:MILLER, MARK ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
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 1:111 MURRAY GUARD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3628
Mailing Address - Country:US
Mailing Address - Phone:731-668-9898
Mailing Address - Fax:731-668-6769
Practice Address - Street 1:111 MURRAY GUARD DR
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3628
Practice Address - Country:US
Practice Address - Phone:731-668-9898
Practice Address - Fax:731-668-6769
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN74851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice