Provider Demographics
NPI:1912917238
Name:WILLIS, MICHAEL S (DMD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
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 1:445 HENSLEE DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055
Mailing Address - Country:US
Mailing Address - Phone:615-441-1441
Mailing Address - Fax:615-441-1460
Practice Address - Street 1:445 HENSLEE DRIVE
Practice Address - Street 2:STE B
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055
Practice Address - Country:US
Practice Address - Phone:615-441-1441
Practice Address - Fax:615-441-1460
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0111771223S0112X
TN96721223S0112X
TNDS96721223S0112X
FLDN111771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24550Medicare PIN
FLU01783Medicare UPIN
FL24650Medicare PIN