Provider Demographics
NPI:1558672618
Name:WILLIS, COLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLE
Middle Name:
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 1:1518 PICKETT AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-3848
Mailing Address - Country:US
Mailing Address - Phone:225-252-7367
Mailing Address - Fax:
Practice Address - Street 1:4450 BLUEBONNET BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9648
Practice Address - Country:US
Practice Address - Phone:225-927-5246
Practice Address - Fax:225-927-1788
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice