Provider Demographics
NPI:1114905619
Name:WILLIS, TIMOTHY O (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:O
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:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46391-0106
Mailing Address - Country:US
Mailing Address - Phone:219-785-4609
Mailing Address - Fax:219-785-4600
Practice Address - Street 1:444 N FLYNN RD
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46391-9647
Practice Address - Country:US
Practice Address - Phone:219-785-4609
Practice Address - Fax:219-785-4600
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007712A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice