MEDICARE: DR. GLEN R 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	0401008691	VA

General Provider Information

NPI Number	:	1891782892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN R MILLER DDS

Provider Business Mailing Address
First Line	:	5249 DUKE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-2919
Country	:	US
Telephone Number	:	703-212-7500
Fax Number	:	703-212-7056

Provider Business Practice Location Address
First Line	:	10509 BRADDOCK RD
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-2239
Country	:	US
Telephone Number	:	703-503-1700
Fax Number	:	703-503-0766

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

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	07/08/2007

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