Provider Demographics
NPI:1710967443
Name:WILLIS, ROBERT ADDISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ADDISON
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 1:204 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-3061
Mailing Address - Country:US
Mailing Address - Phone:620-326-6261
Mailing Address - Fax:620-326-6172
Practice Address - Street 1:204 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3061
Practice Address - Country:US
Practice Address - Phone:620-326-6261
Practice Address - Fax:620-326-6172
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice