Provider Demographics
NPI:1326136326
Name:WILLIS, MARK A (DDS, MS, PA)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:135 N 49TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2317
Mailing Address - Country:US
Mailing Address - Phone:479-452-1336
Mailing Address - Fax:
Practice Address - Street 1:5604 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3224
Practice Address - Country:US
Practice Address - Phone:479-484-7336
Practice Address - Fax:479-484-8128
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100140260AMedicaid