Healthcare Provider Details

I. General information

NPI: 1063433209
Provider Name (Legal Business Name): MCMILLEN ORTHODONTICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 HARTFORD AVE SUITE 101
JOHNSTON RI
02919-7100
US

IV. Provider business mailing address

1226 HARTFORD AVE SUITE 101
JOHNSTON RI
02919-7100
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-7171
  • Fax: 401-331-2755
Mailing address:
  • Phone: 401-331-7171
  • Fax: 401-331-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDEN0149
License Number StateRI

VIII. Authorized Official

Name: DR. FREDERICK H MCMILLEN
Title or Position: OWNER
Credential: DDS
Phone: 401-331-7171