Provider Demographics
NPI:1710796388
Name:TILLEY, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:TILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5918 CRUMBLING RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-1611
Mailing Address - Country:US
Mailing Address - Phone:385-207-5175
Mailing Address - Fax:
Practice Address - Street 1:4 SUNSET WAY STE C
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2016
Practice Address - Country:US
Practice Address - Phone:702-968-1682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE616328001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics