Healthcare Provider Details

I. General information

NPI: 1093919607
Provider Name (Legal Business Name): EVAN N. MILLER, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PROVIDENCE RD
CHARLOTTE NC
28207-1218
US

IV. Provider business mailing address

130 PROVIDENCE RD
CHARLOTTE NC
28207-1218
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-1444
  • Fax:
Mailing address:
  • Phone: 704-377-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5830
License Number StateNC

VIII. Authorized Official

Name: DR. EVAN N MILLER
Title or Position: DENTIST
Credential: DDS
Phone: 704-377-1444