Provider Demographics
NPI:1306049333
Name:MILAM, MARK WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:MILAM
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 1:104 EXCHANGE PL
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-237-5197
Mailing Address - Fax:
Practice Address - Street 1:104 EXCHANGE PL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2571
Practice Address - Country:US
Practice Address - Phone:337-237-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice