MEDICARE: DR. ETHEL MARLENE MILES 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	1223G0001X	General Practice Dentistry	0401 006823	VA
2	1223G0001X	General Practice Dentistry	50053477	NY
3	1223G0001X	General Practice Dentistry	63226209921	UT

General Provider Information

NPI Number	:	1962605675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHEL MARLENE MILES D.D.S.

Provider Business Mailing Address
First Line	:	5 FISCELLA CT
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23669-1865
Country	:	US
Telephone Number	:	757-851-5549
Fax Number	:	757-851-5549

Provider Business Practice Location Address
First Line	:	425 W 20TH ST
Second Line	:	SUITE 3
City	:	NORFOLK
State	:	VA
Zip	:	23517-2128
Country	:	US
Telephone Number	:	757-622-4245
Fax Number	:	757-622-3722

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	07/08/2007

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