MEDICARE: DR. COLETTA M MILLER D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	021-001383	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760488514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLETTA M MILLER D.D.S.

Provider Business Mailing Address
First Line	:	3740 E LAKE CTR
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-224-6789
Fax Number	:	217-224-9675

Provider Business Practice Location Address
First Line	:	3740 E LAKE CTR
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-5805
Country	:	US
Telephone Number	:	217-224-6789
Fax Number	:	217-224-9675

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	08/27/2010

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Directions to “ DR. COLETTA M MILLER D.D.S.” Practice Location

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