Provider Demographics
NPI:1629522396
Name:DAVID WILLIS DMD, LLC
Entity Type:Organization
Organization Name:DAVID WILLIS DMD, LLC
Other - Org Name:WILLIS DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-364-3004
Mailing Address - Street 1:1261 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1959
Mailing Address - Country:US
Mailing Address - Phone:503-364-3004
Mailing Address - Fax:503-364-1623
Practice Address - Street 1:1261 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1959
Practice Address - Country:US
Practice Address - Phone:503-364-3004
Practice Address - Fax:503-364-1623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7786332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1841395977OtherDAVID G. WILLIS, DMD