Provider Demographics
NPI:1689801409
Name:WILLIS, CHARLES STEADMAN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STEADMAN
Last Name:WILLIS
Suffix:III
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 1:1212 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3572
Mailing Address - Country:US
Mailing Address - Phone:919-286-2235
Mailing Address - Fax:919-286-2235
Practice Address - Street 1:1212 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3572
Practice Address - Country:US
Practice Address - Phone:919-286-2235
Practice Address - Fax:919-286-2235
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist