Healthcare Provider Details

I. General information

NPI: 1679739916
Provider Name (Legal Business Name): SUSAN MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE J174
GLENDALE AZ
85306-3703
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE J174
GLENDALE AZ
85306-3703
US

V. Phone/Fax

Practice location:
  • Phone: 623-939-5870
  • Fax: 623-776-9503
Mailing address:
  • Phone: 623-939-5870
  • Fax: 623-776-9503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: