Provider Demographics
NPI:1235357567
Name:WILLSON, BRIAN H (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:H
Last Name:WILLSON
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 1:2019 VALLEYGATE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3688
Mailing Address - Country:US
Mailing Address - Phone:910-484-1555
Mailing Address - Fax:910-323-9287
Practice Address - Street 1:2019 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-484-1555
Practice Address - Fax:910-323-9287
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC62921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice