Provider Demographics
NPI:1093995805
Name:WILLIS, MAURI KIRSTEN JOY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MAURI
Middle Name:KIRSTEN JOY
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MRS
Other - First Name:MAURI
Other - Middle Name:KIRSTEN JOY
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:4303 S KINGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5707
Mailing Address - Country:US
Mailing Address - Phone:509-585-4111
Mailing Address - Fax:
Practice Address - Street 1:4303 S KINGWOOD ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-5707
Practice Address - Country:US
Practice Address - Phone:509-585-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00007964124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist