Healthcare Provider Details

I. General information

NPI: 1467943019
Provider Name (Legal Business Name): MARY LABORDE MILLER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 33RD AVE W
SEATTLE WA
98199-3255
US

IV. Provider business mailing address

303 SHELL BEACH DR
LAKE CHARLES LA
70601-5825
US

V. Phone/Fax

Practice location:
  • Phone: 206-283-7844
  • Fax:
Mailing address:
  • Phone: 337-377-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60949816
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6856
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: