Provider Demographics
NPI:1487749149
Name:MILLER, TODD D (DMD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:D
Last Name:MILLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 MARQUETTE PL S
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-3721
Mailing Address - Country:US
Mailing Address - Phone:815-468-3020
Mailing Address - Fax:815-468-3292
Practice Address - Street 1:190 MARQUETTE PL S
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-3721
Practice Address - Country:US
Practice Address - Phone:815-468-3020
Practice Address - Fax:815-468-3292
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190247811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice