Provider Demographics
NPI:1417168808
Name:WILLIS, TERRI LYNN (DMD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2936
Mailing Address - Country:US
Mailing Address - Phone:770-324-2459
Mailing Address - Fax:
Practice Address - Street 1:113 PLANTATION AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125
Practice Address - Country:US
Practice Address - Phone:770-748-2622
Practice Address - Fax:770-749-1976
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist