Provider Demographics
NPI:1760495832
Name:BRIAN H. WILLSON, D.D.S., P.A.
Entity Type:Organization
Organization Name:BRIAN H. WILLSON, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-484-1555
Mailing Address - Street 1:2019 VALLEYGATE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3688
Mailing Address - Country:US
Mailing Address - Phone:910-484-1555
Mailing Address - Fax:910-323-9287
Practice Address - Street 1:2019 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-484-1555
Practice Address - Fax:910-323-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty