MEDICARE: DR. LATHE EDWARD MILLER D.D.S., M.S.

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	29010118731	MI

General Provider Information

NPI Number	:	1871644989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LATHE EDWARD MILLER D.D.S., M.S.

Provider Business Mailing Address
First Line	:	847 PARCHMENT DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2303
Country	:	US
Telephone Number	:	616-942-9320
Fax Number	:	616-942-1878

Provider Business Practice Location Address
First Line	:	847 PARCHMENT DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2303
Country	:	US
Telephone Number	:	616-942-9320
Fax Number	:	616-942-1878

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

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	07/08/2007

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