Healthcare Provider Details

I. General information

NPI: 1598381113
Provider Name (Legal Business Name): ADAM MILLER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAKE MARY BLVD STE 106
LAKE MARY FL
32746-3501
US

IV. Provider business mailing address

2500 W LAKE MARY BLVD STE 106
LAKE MARY FL
32746-3501
US

V. Phone/Fax

Practice location:
  • Phone: 407-328-6411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN24976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: