1316994700 NPI number — EDMOND HAROLD LILES DDS

Table of content: EDMOND HAROLD LILES DDS (NPI 1316994700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316994700 NPI number — EDMOND HAROLD LILES DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILES
Provider First Name:
EDMOND
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316994700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 B ROBIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTIC BEACH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-726-1277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 WB MCLEAN DR
Provider Second Line Business Practice Location Address:
HARROLD & SHOLAR DDS PA
Provider Business Practice Location Address City Name:
CAPE CARTERET
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-393-8168
Provider Business Practice Location Address Fax Number:
252-393-2978
Provider Enumeration Date:
05/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4220 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7995273 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95273 . This is a "NC BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1346100 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".