Provider Demographics
NPI:1942681069
Name:WILLIS, AVI (DMD, MAST)
Entity Type:Individual
Prefix:DR
First Name:AVI
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DMD, MAST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 RADCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-3311
Mailing Address - Country:US
Mailing Address - Phone:570-332-0689
Mailing Address - Fax:
Practice Address - Street 1:135 SAXONY RD
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3791
Practice Address - Country:US
Practice Address - Phone:760-634-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0403831223P0221X
NJ22DI027652001223P0221X
CADDS1023341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry