Healthcare Provider Details

I. General information

NPI: 1104293877
Provider Name (Legal Business Name): NATHAN KING MILLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21610 PACIFIC HWY
OCEAN PARK WA
98640-3206
US

IV. Provider business mailing address

2813 FIDDLEBACK ST NE
LACEY WA
98516-4426
US

V. Phone/Fax

Practice location:
  • Phone: 360-665-3000
  • Fax:
Mailing address:
  • Phone: 316-393-4493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2015018855
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60938377
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: