Healthcare Provider Details

I. General information

NPI: 1902970734
Provider Name (Legal Business Name): ROGER DUANE MILLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 WEST GRAND RIVER AVE
PORTLAND MI
48875
US

IV. Provider business mailing address

811 WEST GRAND RIVER AVE
PORTLAND MI
48875
US

V. Phone/Fax

Practice location:
  • Phone: 517-647-7878
  • Fax: 517-647-2916
Mailing address:
  • Phone: 517-647-7878
  • Fax: 517-647-2916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901012012
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: