Provider Demographics
NPI:1407093842
Name:TILLER, BRADLEY B (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:B
Last Name:TILLER
Suffix:
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 1:11990 HWY 17 BYPASS UNIT 8
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-7792
Mailing Address - Country:US
Mailing Address - Phone:843-651-0314
Mailing Address - Fax:843-651-3662
Practice Address - Street 1:11990 HWY 17 BYPASS UNIT 8
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-7792
Practice Address - Country:US
Practice Address - Phone:843-651-0314
Practice Address - Fax:843-651-3662
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist