Provider Demographics
NPI:1013016104
Name:WILLIS, SHELDON (DDS)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LAKELAND SQUARE EXT
Mailing Address - Street 2:SUITE 700
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7620
Mailing Address - Country:US
Mailing Address - Phone:601-933-0009
Mailing Address - Fax:
Practice Address - Street 1:1000 LAKELAND SQUARE EXT
Practice Address - Street 2:SUITE 700
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7620
Practice Address - Country:US
Practice Address - Phone:601-933-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3279-031223G0001X
AZD6926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04350504Medicaid