Healthcare Provider Details

I. General information

NPI: 1386205607
Provider Name (Legal Business Name): ERIC MICHAEL NILES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 08/23/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 ALPHARETTA HWY
ROSWELL GA
30076-1490
US

IV. Provider business mailing address

88 LINCOLN PKWY
BUFFALO NY
14222-1012
US

V. Phone/Fax

Practice location:
  • Phone: 470-299-1955
  • Fax:
Mailing address:
  • Phone: 716-912-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123584
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number061139
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: