Basic Information
| Provider Information | |||||||||
| NPI: | 1306163480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64369 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857284369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152548674 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | GRADUATE MEDICAL EDUCATION | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2010 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 51560 | AZ | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.