Provider Demographics
NPI:1538461355
Name:C MICHAEL WILLOCK, DDS, PA
Entity Type:Organization
Organization Name:C MICHAEL WILLOCK, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-942-2154
Mailing Address - Street 1:861 WILLOW DR
Mailing Address - Street 2:STE 1
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-7076
Mailing Address - Country:US
Mailing Address - Phone:919-942-2154
Mailing Address - Fax:919-929-4166
Practice Address - Street 1:861 WILLOW DR
Practice Address - Street 2:STE 1
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7076
Practice Address - Country:US
Practice Address - Phone:919-942-2154
Practice Address - Fax:919-929-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty