MEDICARE: DR. MARK WAYNE MILLER DDS

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	1223G0001X	General Practice Dentistry	25951	CA

General Provider Information

NPI Number	:	1235139544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WAYNE MILLER DDS

Provider Business Mailing Address
First Line	:	5201 DEER VALLEY RD
Second Line	:	STE 3B
City	:	ANTIOCH
State	:	CA
Zip	:	94531-7429
Country	:	US
Telephone Number	:	925-754-6020
Fax Number	:	925-754-5082

Provider Business Practice Location Address
First Line	:	5201 DEER VALLEY RD
Second Line	:	STE 3B
City	:	ANTIOCH
State	:	CA
Zip	:	94531-7429
Country	:	US
Telephone Number	:	925-754-6020
Fax Number	:	925-754-5082

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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