Provider Demographics
NPI:1154381481
Name:MILLER, GARY LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
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 1:806 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-4728
Mailing Address - Country:US
Mailing Address - Phone:337-824-2422
Mailing Address - Fax:337-824-0047
Practice Address - Street 1:806 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4728
Practice Address - Country:US
Practice Address - Phone:337-824-2422
Practice Address - Fax:337-824-0047
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1834394Medicaid
LAG4862OtherBLUE CROSS BLUE SHIELD