Healthcare Provider Details

I. General information

NPI: 1205195047
Provider Name (Legal Business Name): MILLER ENDODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 07/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 CALIFORNIA AVE
SPARTANBURG SC
29303-2271
US

IV. Provider business mailing address

263 CALIFORNIA AVE
SPARTANBURG SC
29303-2271
US

V. Phone/Fax

Practice location:
  • Phone: 864-699-9931
  • Fax: 864-699-9932
Mailing address:
  • Phone: 864-699-9931
  • Fax: 864-699-9932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number784
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWRENCE G MILLER JR.
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 864-699-9931