Healthcare Provider Details

I. General information

NPI: 1871169292
Provider Name (Legal Business Name): ROSS JOHN MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 N BEAVER ST
FLAGSTAFF AZ
86001-3142
US

IV. Provider business mailing address

4760 N BUTLER AVE STE B
FARMINGTON NM
87401-0816
US

V. Phone/Fax

Practice location:
  • Phone: 505-592-0482
  • Fax:
Mailing address:
  • Phone: 505-592-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS36681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: