Healthcare Provider Details

I. General information

NPI: 1093367559
Provider Name (Legal Business Name): KATELYNN NICOLE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 610-334-7797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042332
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDGD.10195
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: