Provider Demographics
NPI:1447570825
Name:LILES, BRADFORD BOWEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:BOWEN
Last Name:LILES
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 1:5721 HIGHWAY 90 STE A
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-3601
Mailing Address - Country:US
Mailing Address - Phone:251-653-1300
Mailing Address - Fax:251-653-1300
Practice Address - Street 1:5721 HIGHWAY 90 STE A
Practice Address - Street 2:
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-3601
Practice Address - Country:US
Practice Address - Phone:251-653-1300
Practice Address - Fax:251-653-1300
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL57621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice