Provider Demographics
NPI:1265650246
Name:WILLIS, LAWRENCE M JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:M
Last Name:WILLIS
Suffix:JR
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 1:6537 E 72ND PL
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-1704
Mailing Address - Country:US
Mailing Address - Phone:303-288-7020
Mailing Address - Fax:
Practice Address - Street 1:6537 E 72ND PL
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-1704
Practice Address - Country:US
Practice Address - Phone:303-288-7020
Practice Address - Fax:
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
CO104956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02049567Medicaid