MEDICARE: DR. MARY LABORDE 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	6856	LA
2	122300000X	Dentist	60949816	WA

General Provider Information

NPI Number	:	1467943019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY LABORDE MILLER DDS

Provider Business Mailing Address
First Line	:	303 SHELL BEACH DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5825
Country	:	US
Telephone Number	:	337-377-6020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 33RD AVE W
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98199-3255
Country	:	US
Telephone Number	:	206-283-7844
Fax Number	:

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

Provider Enumeration Date	:	05/18/2018
Last Update Date	:	07/23/2019

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