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General NPI Number Information
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NPI Number | 1710796388
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Entity Type | Individual
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Provider Name | EDGAR TILLEY
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Gender | Male
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Dates
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Enumeration Date | 01/07/2025
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Last Update Date | 01/07/2025
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Provider Practice Location Address
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Address Line | 4 SUNSET WAY STE C
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City | HENDERSON
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State | NV
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Zip | 89014-2016
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Country | US
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Telephone | 702-968-1682
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Fax |
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Provider Business Mailing Address
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Address Line | 5918 CRUMBLING RIDGE ST
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City | HENDERSON
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State | NV
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Zip | 89011-1611
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Country | US
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Telephone | 385-207-5175
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DE61632800
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License Number State | WA
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