Provider Demographics
NPI:1588371082
Name:MILLER, AMANDA (RDH, PHDH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RDH, PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-0518
Mailing Address - Country:US
Mailing Address - Phone:217-935-3427
Mailing Address - Fax:217-935-9820
Practice Address - Street 1:5924 REVERE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-2914
Practice Address - Country:US
Practice Address - Phone:217-935-3427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020010006124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist