Provider Demographics
NPI:1578554465
Name:WILLIS, HENRY SK IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:SK
Last Name:WILLIS
Suffix:IV
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 1:6811 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8649
Mailing Address - Country:US
Mailing Address - Phone:208-267-6454
Mailing Address - Fax:
Practice Address - Street 1:6811 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8649
Practice Address - Country:US
Practice Address - Phone:208-267-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-37841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice