MEDICARE: DR. JACK W. 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	5448	KS

General Provider Information

NPI Number	:	1942288949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK W. MILLER DDS

Provider Business Mailing Address
First Line	:	2203 SWEETBRIAR ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67204-5518
Country	:	US
Telephone Number	:	316-838-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2203 SWEETBRIAR ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67204-5518
Country	:	US
Telephone Number	:	316-838-1300
Fax Number	:

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

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	07/08/2007

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