Provider Demographics
NPI:1700976727
Name:WILLIS, RALPH GLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:GLEN
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 1:1144-F INDIA HOOK RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-327-4166
Mailing Address - Fax:803-327-2086
Practice Address - Street 1:1144-F INDIA HOOK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-327-4166
Practice Address - Fax:803-327-2086
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice