Provider Demographics
NPI:1881120582
Name:WILLIS, HALEY (DDS)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 OPPOSITION WAY
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6160
Mailing Address - Country:US
Mailing Address - Phone:434-579-5515
Mailing Address - Fax:
Practice Address - Street 1:3616 DURHAM CHAPEL HILL BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2661
Practice Address - Country:US
Practice Address - Phone:919-493-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0257841223P0221X
MD175391223P0221X, 1223G0001X
390200000X
VA04014173501223P0221X
NC2601911223P0221X
MI29010223491223G0001X
NC137091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice