Provider Demographics
NPI:1265020770
Name:WILLIS, ROBERT A (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 WADDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9066
Mailing Address - Country:US
Mailing Address - Phone:919-917-8250
Mailing Address - Fax:
Practice Address - Street 1:177 WADDINGTON RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9066
Practice Address - Country:US
Practice Address - Phone:919-917-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121091223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice