Provider Demographics
NPI:1306918172
Name:PARKS, WILLIE JOE JR (DDS, MD)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:JOE
Last Name:PARKS
Suffix:JR
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2017
Mailing Address - Country:US
Mailing Address - Phone:903-526-7977
Mailing Address - Fax:903-526-7989
Practice Address - Street 1:815 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2017
Practice Address - Country:US
Practice Address - Phone:903-526-7977
Practice Address - Fax:903-526-7989
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1113110-02Medicaid
TX1113110-03Medicaid
TX0808586-01Medicaid
TX00604EMedicare ID - Type UnspecifiedGROUP#
TX1113110-03Medicaid
TX190009591Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TX0808586-01Medicaid