MEDICARE: MICHELLE MILLER RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	10040	TX

General Provider Information

NPI Number	:	1174120927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MILLER RDH

Provider Business Mailing Address
First Line	:	3725 N LIGHTHOUSE HILL LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3827
Country	:	US
Telephone Number	:	817-905-2055
Fax Number	:

Provider Business Practice Location Address
First Line	:	3725 N LIGHTHOUSE HILL LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3827
Country	:	US
Telephone Number	:	817-905-2055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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