1962605675 NPI number — DR. ETHEL MARLENE MILES D.D.S.

Table of content: DR. ETHEL MARLENE MILES D.D.S. (NPI 1962605675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962605675 NPI number — DR. ETHEL MARLENE MILES D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILES
Provider First Name:
ETHEL
Provider Middle Name:
MARLENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREENE
Provider Other First Name:
ETHEL
Provider Other Middle Name:
MARLENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1962605675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 FISCELLA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23669-1865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-851-5549
Provider Business Mailing Address Fax Number:
757-851-5549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W 20TH ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23517-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-622-4245
Provider Business Practice Location Address Fax Number:
757-622-3722
Provider Enumeration Date:
06/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  0401 006823 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 50053477 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 63226209921 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)