Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2498-89 | MS |
NPI | 1003094079 |
---|---|
Provider Name | Dr. Larry Randall Miller |
First Address | Flowood, MS 39232-9541 |
Second Address | Flowood, MS 39232-9541 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2008 |
Last Update Date | 01/02/2008 |