Provider Demographics
NPI:1720129307
Name:ALBERT E. WILLIS, D.M.D., M.D., P.C.
Entity Type:Organization
Organization Name:ALBERT E. WILLIS, D.M.D., M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:256-464-7873
Mailing Address - Street 1:540 HUGHES RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8999
Mailing Address - Country:US
Mailing Address - Phone:256-464-7873
Mailing Address - Fax:256-464-7864
Practice Address - Street 1:540 HUGHES RD
Practice Address - Street 2:SUITE 6
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8999
Practice Address - Country:US
Practice Address - Phone:256-464-7873
Practice Address - Fax:256-464-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16039261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF10242Medicare UPIN