Provider Demographics
NPI:1568684702
Name:WILLIS, WENDY H (RDH)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:H
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:E HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108
Mailing Address - Country:US
Mailing Address - Phone:860-528-1359
Mailing Address - Fax:
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:E HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004170124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist