Provider Demographics
NPI:1982759429
Name:MILLER, RUSSELL STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:STEPHEN
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 1:1815 CLINTEN AVE SOUTH
Mailing Address - Street 2:SUITE 640
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-442-0990
Mailing Address - Fax:585-442-7310
Practice Address - Street 1:1815 CLINTEN AVE SOUTH
Practice Address - Street 2:SUITE 640
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-442-0990
Practice Address - Fax:585-942-7310
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0327781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00463272Medicaid
NY7696OtherEXCELLUS BLUE CROSS BLUE