Provider Demographics
NPI:1477127488
Name:LILES, MASON COPELAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:MASON
Middle Name:COPELAND
Last Name:LILES
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 1:201 MEDALIST RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8150
Mailing Address - Country:US
Mailing Address - Phone:318-614-5251
Mailing Address - Fax:
Practice Address - Street 1:4279 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259-5189
Practice Address - Country:US
Practice Address - Phone:318-248-4986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA71991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty