Provider Demographics
NPI:1346358678
Name:LILEY, LOUIS JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:
Last Name:LILEY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3926
Mailing Address - Country:US
Mailing Address - Phone:970-221-1400
Mailing Address - Fax:970-221-1433
Practice Address - Street 1:1025 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3926
Practice Address - Country:US
Practice Address - Phone:970-221-1400
Practice Address - Fax:970-221-1433
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COA006701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice