Provider Demographics
NPI:1689993917
Name:WILLENS, SAMUEL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:WILLENS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:C/O DEPT. OF SURGERY, DIVISION OF DENTAL AND ORAL MED
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:C/O DEPT. OF SURGERY, DIVISION OF DENTAL AND ORAL MED
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-3436
Practice Address - Fax:708-327-3489
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist