Provider Demographics
NPI:1841503984
Name:MILLER, BRODEN JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:BRODEN
Middle Name:JOSEPH
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 1:1616 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4244
Mailing Address - Country:US
Mailing Address - Phone:337-478-3232
Mailing Address - Fax:337-478-3206
Practice Address - Street 1:1616 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4244
Practice Address - Country:US
Practice Address - Phone:337-478-3232
Practice Address - Fax:337-478-3206
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH60971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice