Provider Demographics
NPI:1457433427
Name:WILLEY, ROBERT L (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:WILLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:PO BOX 101
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0101
Mailing Address - Country:US
Mailing Address - Phone:760-992-0054
Mailing Address - Fax:760-111-1111
Practice Address - Street 1:71 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-0101
Practice Address - Country:US
Practice Address - Phone:760-920-0542
Practice Address - Fax:760-111-1111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0324141223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics