Provider Demographics
NPI:1992397384
Name:WILLARDSON, JULIANN COVINGTON (DMD)
Entity Type:Individual
Prefix:
First Name:JULIANN
Middle Name:COVINGTON
Last Name:WILLARDSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JULIANN
Other - Middle Name:
Other - Last Name:COVINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 DESERT SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1038
Mailing Address - Country:US
Mailing Address - Phone:208-587-3988
Mailing Address - Fax:208-587-3324
Practice Address - Street 1:120 DESERT SAGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-1038
Practice Address - Country:US
Practice Address - Phone:208-587-3988
Practice Address - Fax:208-587-3324
Is Sole Proprietor?:No
Enumeration Date:2021-02-07
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD-5314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program