Provider Demographics
NPI:1568535011
Name:WILLIS, WARREN RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:RICHARD
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N WARDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3040
Mailing Address - Country:US
Mailing Address - Phone:208-365-6313
Mailing Address - Fax:208-365-1303
Practice Address - Street 1:119 N WARDWELL AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3040
Practice Address - Country:US
Practice Address - Phone:208-365-6313
Practice Address - Fax:208-365-1303
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice