Provider Demographics
NPI:1679913610
Name:MILLER, JACQUELYN OLBINA (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:OLBINA
Last Name:MILLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 S 14TH ST STE 21
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1965
Mailing Address - Country:US
Mailing Address - Phone:904-277-8500
Mailing Address - Fax:
Practice Address - Street 1:1699 S 14TH ST STE 21
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1965
Practice Address - Country:US
Practice Address - Phone:904-277-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDL202311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice