Healthcare Provider Details

I. General information

NPI: 1356411219
Provider Name (Legal Business Name): STEVEN KENT TILLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 WEST LUCAS
CRESTON IA
50801
US

IV. Provider business mailing address

304 WEST LUCAS
CRESTON IA
50801
US

V. Phone/Fax

Practice location:
  • Phone: 641-782-4747
  • Fax: 641-782-8004
Mailing address:
  • Phone: 641-782-4747
  • Fax: 641-782-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number05730
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: