Provider Demographics
NPI:1083728745
Name:WILES, GRANT DOUGLAS (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DOUGLAS
Last Name:WILES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 VALLEYGATE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3688
Mailing Address - Country:US
Mailing Address - Phone:910-485-8885
Mailing Address - Fax:910-485-8287
Practice Address - Street 1:2029 VALLEYGATE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-485-8885
Practice Address - Fax:910-485-8287
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901426Medicaid
NCV05967Medicare UPIN