MEDICARE: JACOB S MILLER, DDS, PLLC

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	L2901020673	MI

General Provider Information

NPI Number	:	1689119414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACOB S MILLER, DDS, PLLC

Provider Business Mailing Address
First Line	:	6689 GRAN VIA DR NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341-9689
Country	:	US
Telephone Number	:	616-901-9148
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 5 MILE RD NE
Second Line	:	SUITE #101
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-6518
Country	:	US
Telephone Number	:	616-364-7039
Fax Number	:	616-364-6068

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JACOB S MILLER
Credential	:	DDS
Telephone Number	:	616-901-9148

Provider Enumeration Date	:	01/03/2017
Last Update Date	:	01/03/2017

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