Healthcare Provider Details

I. General information

NPI: 1104982016
Provider Name (Legal Business Name): MARK D. MILLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W BROADWAY UNIT 106
LOUISVILLE KY
40203-2082
US

IV. Provider business mailing address

15142 ROSARIO RD
FRISCO TX
75035-5439
US

V. Phone/Fax

Practice location:
  • Phone: 270-885-0165
  • Fax: 270-886-2224
Mailing address:
  • Phone: 270-889-3686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number6861
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number36087
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6861
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6861
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: