Provider Demographics
NPI:1609354877
Name:MATTHEW LEE MILLER
Entity type:Organization
Organization Name:MATTHEW LEE MILLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-229-5851
Mailing Address - Street 1:372 MIDDLEWAY PIKE STE A
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-3909
Mailing Address - Country:US
Mailing Address - Phone:304-229-5851
Mailing Address - Fax:304-229-0666
Practice Address - Street 1:372 MIDDLEWAY PIKE STE A
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-3909
Practice Address - Country:US
Practice Address - Phone:304-229-5851
Practice Address - Fax:304-229-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1912922873Medicaid
WV1790048247Medicaid