Provider Demographics
NPI:1104982206
Name:WILLIS, NANCY (DDS)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2005
Mailing Address - Country:US
Mailing Address - Phone:570-343-8885
Mailing Address - Fax:
Practice Address - Street 1:387 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-2005
Practice Address - Country:US
Practice Address - Phone:570-343-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS 027099-L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS 027099-LOtherPA STATE DENTAL LICENSE
PA0012201610001Medicaid
PA669980OtherUNITED CONCORDIA