=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124313291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY C MILLAR D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2011
-----------------------------------------------------
Last Update Date | 07/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 S BOWIE DR
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-594-4788
-----------------------------------------------------
Fax | 817-594-5543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S BOWIE DR
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-594-4788
-----------------------------------------------------
Fax | 817-594-5543
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 27033
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------