Provider Demographics
NPI:1841265204
Name:WILLETTS, BRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:WILLETTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14213 QUAIL CREEK WAY
Mailing Address - Street 2:#312
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-8877
Mailing Address - Country:US
Mailing Address - Phone:410-472-4587
Mailing Address - Fax:410-357-0880
Practice Address - Street 1:1321 MOUNT CARMEL RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9763
Practice Address - Country:US
Practice Address - Phone:410-357-5151
Practice Address - Fax:410-357-0880
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD78671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice