Healthcare Provider Details

I. General information

NPI: 1760463582
Provider Name (Legal Business Name): DEAN MICHAEL MILLER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 ROUTE 58
RIVERHEAD NY
11901-2019
US

IV. Provider business mailing address

1053 RT. 58
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-7777
  • Fax: 631-727-7822
Mailing address:
  • Phone: 631-727-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV0052712
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTUV0052712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: