Provider Demographics
NPI:1528144003
Name:NILES, CHARLES GORDON (DDS MS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GORDON
Last Name:NILES
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:C
Other - Middle Name:GORDON
Other - Last Name:NILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS PC
Mailing Address - Street 1:8082 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114
Mailing Address - Country:US
Mailing Address - Phone:810-227-1950
Mailing Address - Fax:810-227-3414
Practice Address - Street 1:8082 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114
Practice Address - Country:US
Practice Address - Phone:810-227-1950
Practice Address - Fax:810-227-3414
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010104631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics