Provider Demographics
NPI:1952431736
Name:REESE, WILLIS EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:EDWARD
Last Name:REESE
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 1:626 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5739
Mailing Address - Country:US
Mailing Address - Phone:731-885-3561
Mailing Address - Fax:731-885-3097
Practice Address - Street 1:626 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5739
Practice Address - Country:US
Practice Address - Phone:731-885-3561
Practice Address - Fax:731-885-3097
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS43641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3044538OtherBCBST PROVIDER NUMBER