Provider Demographics
NPI:1639203870
Name:TILLES, KENNETH (OD, PA)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:TILLES
Suffix:
Gender:M
Credentials:OD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DULANEY VALLEY RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-1010
Mailing Address - Country:US
Mailing Address - Phone:410-828-4133
Mailing Address - Fax:410-828-4646
Practice Address - Street 1:825 DULANEY VALLEY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-1010
Practice Address - Country:US
Practice Address - Phone:410-828-4133
Practice Address - Fax:410-828-4646
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist