Healthcare Provider Details

I. General information

NPI: 1154176287
Provider Name (Legal Business Name): EDWARD MCMILLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 08/28/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 WEST D. L. INGRAM AVE BLDG 1408
CANNON AFB NM
88103-5014
US

IV. Provider business mailing address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDGD.10823
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10823
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: