Healthcare Provider Details

I. General information

NPI: 1194714014
Provider Name (Legal Business Name): RODRIC LEDELL MILLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5124 STAGE RD
MEMPHIS TN
38134-3164
US

IV. Provider business mailing address

5124 STAGE RD
MEMPHIS TN
38134-3164
US

V. Phone/Fax

Practice location:
  • Phone: 901-373-5433
  • Fax: 901-373-7322
Mailing address:
  • Phone: 901-373-5433
  • Fax: 901-373-7322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS0000007946
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7946
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: