Provider Demographics
NPI:1619084662
Name:WILLIS, TODD BRADFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:BRADFORD
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 1:1615 WOODED ACRES DRIVE
Mailing Address - Street 2:#F
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2863
Mailing Address - Country:US
Mailing Address - Phone:254-776-7242
Mailing Address - Fax:254-776-0696
Practice Address - Street 1:1615 WOODED ACRES DRIVE
Practice Address - Street 2:SUITE #F
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2863
Practice Address - Country:US
Practice Address - Phone:254-776-7242
Practice Address - Fax:254-776-0696
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist