Provider Demographics
NPI:1467513606
Name:WILLEN, DAVID MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:WILLEN
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 1:2775 BISHOP RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2683
Mailing Address - Country:US
Mailing Address - Phone:440-944-7775
Mailing Address - Fax:440-944-7887
Practice Address - Street 1:2775 BISHOP RD
Practice Address - Street 2:SUITE C
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-2683
Practice Address - Country:US
Practice Address - Phone:440-944-7775
Practice Address - Fax:440-944-7887
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0143451223G0001X
OH30014345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
34-1910479OtherTAX ID