Provider Demographics
NPI:1871762773
Name:MILLER, JOHN RANDALL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDALL
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 GODFREY RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2426
Mailing Address - Country:US
Mailing Address - Phone:618-468-4414
Mailing Address - Fax:618-468-2394
Practice Address - Street 1:5800 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2426
Practice Address - Country:US
Practice Address - Phone:618-468-4414
Practice Address - Fax:618-468-2394
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9176253Medicaid