Healthcare Provider Details

I. General information

NPI: 1750580254
Provider Name (Legal Business Name): MATTHEW L MILNER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N STE 266
JACKSON MS
39211-5932
US

IV. Provider business mailing address

4500 I 55 N STE 266
JACKSON MS
39211-5932
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-8920
  • Fax:
Mailing address:
  • Phone: 601-932-8920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3446-08
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberPROS-444-11
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: