Provider Demographics
NPI:1194714014
Name:MILLER, RODRIC LEDELL (DDS)
Entity type:Individual
Prefix:DR
First Name:RODRIC
Middle Name:LEDELL
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 1:5124 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3164
Mailing Address - Country:US
Mailing Address - Phone:901-373-5433
Mailing Address - Fax:901-373-7322
Practice Address - Street 1:5124 STAGE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3164
Practice Address - Country:US
Practice Address - Phone:901-373-5433
Practice Address - Fax:901-373-7322
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000079461223G0001X
TN79461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152431608Medicaid
AR152431608Medicaid