Provider Demographics
NPI:1053599415
Name:MILLER, MARK P (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 IRVINE BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3509
Mailing Address - Country:US
Mailing Address - Phone:714-838-0010
Mailing Address - Fax:714-838-0011
Practice Address - Street 1:1254 IRVINE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3509
Practice Address - Country:US
Practice Address - Phone:714-838-0010
Practice Address - Fax:714-838-0011
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist