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General NPI Number Information
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NPI Number | 1649670936
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Entity Type | Organization
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Legal Business Name | BRADFORD B. LILES, DMD, PC
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Dates
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Enumeration Date | 08/25/2014
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Last Update Date | 08/25/2014
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Provider Practice Location Address
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Address Line | 5721 HIGHWAY 90 STE A
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City | THEODORE
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State | AL
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Zip | 36582-3601
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Country | US
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Telephone | 251-653-1300
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Fax | 251-653-1242
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Provider Business Mailing Address
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Address Line | 5721 HIGHWAY 90 STE A
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City | THEODORE
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State | AL
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Zip | 36582-3601
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Country | US
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Telephone | 251-653-1300
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Fax | 251-653-1242
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | BRADFORD BOWEN LILES
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Credential | DMD
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Telephone | 251-653-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5762
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License Number State | AL
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