Provider Demographics
NPI:1053600262
Name:MILLER DENTAL
Entity type:Organization
Organization Name:MILLER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-413-6000
Mailing Address - Street 1:3610 S.COOPER ST. 112
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015
Mailing Address - Country:US
Mailing Address - Phone:817-466-1500
Mailing Address - Fax:
Practice Address - Street 1:3307 MILLER AVE SUITE A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119
Practice Address - Country:US
Practice Address - Phone:818-413-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22079122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1417171281Medicaid