=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780779173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN L. WILES D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CONRAD HARCOURT WAY
-----------------------------------------------------
City | RUSHVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46173-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-932-5533
-----------------------------------------------------
Fax | 765-932-4569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10270 N. FIVE POINTS ROAD
-----------------------------------------------------
City | KNIGHTSTOWN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-932-5533
-----------------------------------------------------
Fax | 765-932-4569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12010080
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------