Provider Demographics
NPI:1659586485
Name:WILLIS, JULIUS A JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JULIUS
Middle Name:A
Last Name:WILLIS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-1086
Mailing Address - Country:US
Mailing Address - Phone:228-769-9010
Mailing Address - Fax:228-762-0303
Practice Address - Street 1:1226 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-4348
Practice Address - Country:US
Practice Address - Phone:228-769-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1858-791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice