Provider Demographics
NPI:1063627982
Name:WILLIS, ALAN D (DDS)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
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 1:13340 BRIDGEFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-3489
Mailing Address - Country:US
Mailing Address - Phone:238-495-7782
Mailing Address - Fax:
Practice Address - Street 1:1915 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2980
Practice Address - Country:US
Practice Address - Phone:618-242-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A126431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics