MEDICARE: NEWTONVILLE DENTAL GROUP, LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1942708219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEWTONVILLE DENTAL GROUP, LLC

Provider Business Mailing Address
First Line	:	500 CHAPMAN ST UNIT 201
Second Line	:
City	:	CANTON
State	:	MA
Zip	:	02021-2040
Country	:	US
Telephone Number	:	781-562-0457
Fax Number	:

Provider Business Practice Location Address
First Line	:	456 NEWTONVILLE AVE
Second Line	:
City	:	NEWTONVILLE
State	:	MA
Zip	:	02460-1925
Country	:	US
Telephone Number	:	617-244-4133
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD TODD MILLER
Credential	:	DMD
Telephone Number	:	781-562-0457

Provider Enumeration Date	:	01/31/2018
Last Update Date	:	01/31/2018

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