Basic Information
| Provider Information | |||||||||
| NPI: | 1699942532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX AD | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959921396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307513769 | ||||||||
| FaxNumber: | 5307511237 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | COLUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959322534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304585165 | ||||||||
| FaxNumber: | 5304587830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 20295 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.