Provider Demographics
NPI:1760697437
Name:J.A. WILLIS, DMD AND RUSSELL PARKER, DMD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:J.A. WILLIS, DMD AND RUSSELL PARKER, DMD FAMILY DENTISTRY
Other - Org Name:WILLIS & PARKER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-769-9010
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-1086
Mailing Address - Country:US
Mailing Address - Phone:228-769-9010
Mailing Address - Fax:228-762-0303
Practice Address - Street 1:1226 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-4348
Practice Address - Country:US
Practice Address - Phone:228-769-9010
Practice Address - Fax:228-762-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1858-791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty