Provider Demographics
NPI:1881748390
Name:MILLER, CARL BRADLEY (DDS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:BRADLEY
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:C
Other - Middle Name:BRADLEY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2500 MARINA BAY DR STE Z
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2855
Mailing Address - Country:US
Mailing Address - Phone:573-268-2505
Mailing Address - Fax:
Practice Address - Street 1:2500 MARINA BAY DR STE Z
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2855
Practice Address - Country:US
Practice Address - Phone:573-268-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015407122300000X
TX376801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist