Provider Demographics
NPI:1538273198
Name:MILLER, DONALD T JR (DMD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:T
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:IL
Mailing Address - Zip Code:60135-1309
Mailing Address - Country:US
Mailing Address - Phone:815-784-5166
Mailing Address - Fax:815-784-5167
Practice Address - Street 1:619 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1309
Practice Address - Country:US
Practice Address - Phone:815-784-5166
Practice Address - Fax:815-784-5167
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice