Healthcare Provider Details

I. General information

NPI: 1043207004
Provider Name (Legal Business Name): MATTHEW BRADEN BURNS MILLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349
US

IV. Provider business mailing address

12 SOMERSET LN
OLD LYME CT
06371-1737
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-3094
  • Fax:
Mailing address:
  • Phone: 301-775-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00009227
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12339
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: