Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 4109 | SC |
Y | 1223E0200X | Endodontist | 784 | SC |
NPI | 1053457960 |
---|---|
Provider Name | Dr. Lawrence Gary Miller JR. |
First Address | Spartanburg, SC 29303-2271 |
Second Address | Spartanburg, SC 29303-2271 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2007 |
Last Update Date | 28/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ZX4109 | (05) | SC |