Basic Information
| Provider Information | |||||||||
| NPI: | 1609389493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLS | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLS | ||||||||
| OtherFirstName: | CLAYTON | ||||||||
| OtherMiddleName: | RAY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CLAY | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8406 DUDLEY DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782304521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109204533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20821 US HIGHWAY 281 N STE 310 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782587597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104944488 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2017 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 33067 | TX | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 33067 | 01 | TX | DENTAL LICENSE | OTHER | FW6969173 | 01 | TX | DEA | OTHER |