Healthcare Provider Details

I. General information

NPI: 1194962480
Provider Name (Legal Business Name): KATHRYN JOY MILLER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN JOY BAGG D.D.S.

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 N VALLEY DR
MANHATTAN BEACH CA
90266-2667
US

IV. Provider business mailing address

2503 N VALLEY DR
MANHATTAN BEACH CA
90266-2667
US

V. Phone/Fax

Practice location:
  • Phone: 310-318-5359
  • Fax:
Mailing address:
  • Phone: 310-318-5359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number53144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: