Provider Demographics
NPI:1518061605
Name:WILLIS, WESTON ALEXANDER (DDS MSC O)
Entity Type:Individual
Prefix:DR
First Name:WESTON
Middle Name:ALEXANDER
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DDS MSC O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 DEER CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CARTERET
Mailing Address - State:NC
Mailing Address - Zip Code:28584
Mailing Address - Country:US
Mailing Address - Phone:252-393-8344
Mailing Address - Fax:
Practice Address - Street 1:17 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-3219
Practice Address - Country:US
Practice Address - Phone:910-353-5234
Practice Address - Fax:910-353-1999
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8999384Medicaid
NC99384OtherBLUE CROSS BLUE SHIELD NC
T97078Medicare UPIN
NC241138AMedicare ID - Type Unspecified