Healthcare Provider Details

I. General information

NPI: 1851361901
Provider Name (Legal Business Name): LESLIE C. MILLAR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRANCH HEALTH CLINIC BLD. 3911 EAST AVE. SUITE B
PENSACOLA NAVAL AIR STATION FL
32508-5141
US

IV. Provider business mailing address

5501 WILLARD NORRIS RD
MILTON FL
32570-8817
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-8970
  • Fax: 850-452-8978
Mailing address:
  • Phone: 850-981-3447
  • Fax: 850-452-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberA00328
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: