1629522396 NPI number — DAVID WILLIS DMD, LLC

Table of content: (NPI 1629522396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629522396 NPI number — DAVID WILLIS DMD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID WILLIS DMD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILLIS DENTAL
Provider Other Organization Name Type Code:
5
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:
1629522396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1261 LANCASTER DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-1959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-364-3004
Provider Business Mailing Address Fax Number:
503-364-1623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1261 LANCASTER DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-1959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-364-3004
Provider Business Practice Location Address Fax Number:
503-364-1623
Provider Enumeration Date:
08/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
503-364-3004

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  D7786 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1841395977 . This is a "DAVID G. WILLIS, DMD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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