Provider Demographics
NPI:1407344294
Name:WILLARDSON, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILLARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-7827
Mailing Address - Country:US
Mailing Address - Phone:918-333-4500
Mailing Address - Fax:918-334-4509
Practice Address - Street 1:5401 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-7827
Practice Address - Country:US
Practice Address - Phone:918-333-4500
Practice Address - Fax:918-334-4509
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200540820BMedicaid