Provider Demographics
NPI:1679191795
Name:WILLIS, CAMERON (DDS)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
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 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-988-0996
Mailing Address - Fax:
Practice Address - Street 1:1406 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:MO
Practice Address - Zip Code:64865-9261
Practice Address - Country:US
Practice Address - Phone:417-776-2291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7347122300000X
KS61778122300000X
MO20220145741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist