Provider Demographics
NPI:1922116292
Name:BEENE, WILLIS TILMON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIS
Middle Name:TILMON
Last Name:BEENE
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:P.O. BOX 1133
Mailing Address - Street 2:615 N. JACKSON ST.
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754
Mailing Address - Country:US
Mailing Address - Phone:870-234-1110
Mailing Address - Fax:870-234-1112
Practice Address - Street 1:615 N. JACKSON ST.
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71754
Practice Address - Country:US
Practice Address - Phone:870-234-1110
Practice Address - Fax:870-234-1112
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101570608Medicaid