=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417036583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL K MCMILLAN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 06/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 E 50 S
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-756-0900
-----------------------------------------------------
Fax | 801-756-7290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 E 50 S
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-756-0900
-----------------------------------------------------
Fax | 801-756-7290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 142879-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 142879-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------