Provider Demographics
NPI:1619085701
Name:WILLY, PAUL RICHARD (DENTIST DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RICHARD
Last Name:WILLY
Suffix:
Gender:M
Credentials:DENTIST DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702
Mailing Address - Country:US
Mailing Address - Phone:319-291-3908
Mailing Address - Fax:319-291-4077
Practice Address - Street 1:1950 PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702
Practice Address - Country:US
Practice Address - Phone:319-291-3908
Practice Address - Fax:319-291-4077
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6925122300000X
WI3203015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist