Healthcare Provider Details

I. General information

NPI: 1689946980
Provider Name (Legal Business Name): MILLER & HENRIOD DENTAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 N HILL AVE
PASADENA CA
91106-1905
US

IV. Provider business mailing address

72 N HILL AVE
PASADENA CA
91106-1905
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-5386
  • Fax:
Mailing address:
  • Phone: 626-796-5386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number21921
License Number StateCA

VIII. Authorized Official

Name: DR. RONALD WADE MILLER
Title or Position: OWNER
Credential: DDS
Phone: 626-796-5386