Provider Demographics
NPI:1821091349
Name:WILLIS, CATHARINE B (DMD)
Entity Type:Individual
Prefix:DR
First Name:CATHARINE
Middle Name:B
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4258 HIGHWAY 231
Mailing Address - Street 2:STE 1
Mailing Address - City:LACEYS SPRING
Mailing Address - State:AL
Mailing Address - Zip Code:35754-6444
Mailing Address - Country:US
Mailing Address - Phone:256-498-3570
Mailing Address - Fax:256-498-1054
Practice Address - Street 1:4258 HIGHWAY 231
Practice Address - Street 2:STE 1
Practice Address - City:LACEYS SPRING
Practice Address - State:AL
Practice Address - Zip Code:35754-6444
Practice Address - Country:US
Practice Address - Phone:256-498-3570
Practice Address - Fax:256-498-1054
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL90527OtherBLUE CROSS BLUE SHIELD
AL008703960Medicaid