Provider Demographics
NPI:1104074525
Name:WILLOUGHBY, HAMIL J (DDS)
Entity type:Individual
Prefix:DR
First Name:HAMIL
Middle Name:J
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:HAMIL
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:59 MEREDITH AVE
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-3224
Mailing Address - Country:US
Mailing Address - Phone:631-725-8798
Mailing Address - Fax:
Practice Address - Street 1:184 SULLIVAN HALL
Practice Address - Street 2:STONY BROOK UNIVERSITY SCHOOL OF DENTAL MEDICINE
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8705
Practice Address - Country:US
Practice Address - Phone:631-632-8975
Practice Address - Fax:631-632-3747
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0272221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery