Basic Information
| Provider Information | |||||||||
| NPI: | 1053865410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 RIVERSTONE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704790600 | ||||||||
| FaxNumber: | 7704790599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 RIVERSTONE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704790600 | ||||||||
| FaxNumber: | 7704790599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN015236 | GA | Y | Dental Providers | Dentist | General Practice |
No ID Information.