Provider Demographics
NPI:1730699802
Name:MILLER DENTAL PLLC
Entity type:Organization
Organization Name:MILLER DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-413-6000
Mailing Address - Street 1:3307 MILLER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-1971
Mailing Address - Country:US
Mailing Address - Phone:817-413-6000
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:817-413-6000
Practice Address - Fax:817-413-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220791223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX272246221Medicaid