Healthcare Provider Details

I. General information

NPI: 1760488514
Provider Name (Legal Business Name): COLETTA M MILLER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 E LAKE CTR
QUINCY IL
62305-5805
US

IV. Provider business mailing address

3740 E LAKE CTR
QUINCY IL
62305-5805
US

V. Phone/Fax

Practice location:
  • Phone: 217-224-6789
  • Fax: 217-224-9675
Mailing address:
  • Phone: 217-224-6789
  • Fax: 217-224-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021-001383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: