Provider Demographics
NPI:1326136326
Name:WILLIS, MARK A (DDS, MS, PA)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:
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Mailing Address - Street 1:1390 NATCHEZ WAY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1084
Mailing Address - Country:US
Mailing Address - Phone:770-337-1835
Mailing Address - Fax:
Practice Address - Street 1:1795 RESURGENCE DR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7306
Practice Address - Country:US
Practice Address - Phone:479-692-1392
Practice Address - Fax:770-982-0005
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AR26341223P0221X
GADN0155761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100140260AMedicaid