Provider Demographics
NPI:1285016154
Name:BRADLEY W. WILLIS,
Entity Type:Organization
Organization Name:BRADLEY W. WILLIS,
Other - Org Name:WILLIS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-260-2929
Mailing Address - Street 1:8161 SEATON PL STE A
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-7205
Mailing Address - Country:US
Mailing Address - Phone:334-260-2929
Mailing Address - Fax:334-396-7874
Practice Address - Street 1:8161 SEATON PL STE A
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-7205
Practice Address - Country:US
Practice Address - Phone:334-260-2929
Practice Address - Fax:334-396-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4554261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental