Healthcare Provider Details

I. General information

NPI: 1912251497
Provider Name (Legal Business Name): JENNY LEE MILLER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987C CHERRY ST E
CANAL FULTON OH
44614-9609
US

IV. Provider business mailing address

2344 HEIDELBERG AVE SE
MASSILLON OH
44646-7456
US

V. Phone/Fax

Practice location:
  • Phone: 330-854-1337
  • Fax:
Mailing address:
  • Phone: 330-437-8415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number31.013286
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: