MEDICARE: DR. JACQUELINE MARIE MILLER DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	015380	MO

General Provider Information

NPI Number	:	1578567400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE MARIE MILLER DDS, MS

Provider Business Mailing Address
First Line	:	1015 WASHINGTON SQUARE SHOPPING CTR
Second Line	:	STE G
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-4004
Fax Number	:	636-239-6576

Provider Business Practice Location Address
First Line	:	1015 WASHINGTON SQUARE SHOPPING CTR
Second Line	:	STE G
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-4004
Fax Number	:	636-239-6576

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/08/2007

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