Provider Demographics
NPI:1447624465
Name:WILLIS, HAROLD JR
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:WILLIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAC FORT CAVAZOS
Mailing Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:205-915-9827
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAC FORT CAVAZOS
Practice Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:910-643-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31556122300000X
NC117371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist