Provider Demographics
NPI:1437285798
Name:WILLIARD, MARY E (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WILLIARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 MILUK DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-7728
Mailing Address - Country:US
Mailing Address - Phone:541-982-3414
Mailing Address - Fax:
Practice Address - Street 1:630 MILUK DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7728
Practice Address - Country:US
Practice Address - Phone:907-382-2188
Practice Address - Fax:541-888-4435
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD16151Medicaid
OR500797447Medicaid