Provider Demographics
NPI:1184024630
Name:WILLIS, ALBERT II (DMD, MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:WILLIS
Suffix:II
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 HUGHES RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8999
Mailing Address - Country:US
Mailing Address - Phone:256-464-7873
Mailing Address - Fax:256-464-7864
Practice Address - Street 1:540 HUGHES RD
Practice Address - Street 2:SUITE 6
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8999
Practice Address - Country:US
Practice Address - Phone:256-464-7873
Practice Address - Fax:256-464-7864
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16039204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF10242Medicare UPIN