Healthcare Provider Details

I. General information

NPI: 1467542423
Provider Name (Legal Business Name): CHARLES A. MILLER III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 SE 43RD AVE
MILWAUKIE OR
97222-5768
US

IV. Provider business mailing address

9701 SE 43RD AVE
MILWAUKIE OR
97222-5768
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-1322
  • Fax: 503-659-4880
Mailing address:
  • Phone: 503-659-1322
  • Fax: 503-659-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4902
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: