Healthcare Provider Details

I. General information

NPI: 1700916624
Provider Name (Legal Business Name): MILLER ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EAST BROADWAY
JACKSON WY
83001-3996
US

IV. Provider business mailing address

PO BOX 3996 200 EAST BROADWAY
JACKSON WY
83001-3996
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4021
  • Fax:
Mailing address:
  • Phone: 307-733-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN MILLER
Title or Position: PRESIDENT
Credential:
Phone: 307-733-4021