Provider Demographics
NPI:1417187642
Name:WILLIS, JAMES WALTEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALTEN
Last Name:WILLIS
Suffix:
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 1:6948 WELBOURNE LN
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3346
Mailing Address - Country:US
Mailing Address - Phone:304-906-5300
Mailing Address - Fax:
Practice Address - Street 1:41 S MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2333
Practice Address - Country:US
Practice Address - Phone:540-885-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist