Provider Demographics
NPI:1366602724
Name:WILLSON, AARON ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:ANTHONY
Last Name:WILLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5307
Mailing Address - Country:US
Mailing Address - Phone:269-323-3128
Mailing Address - Fax:
Practice Address - Street 1:621 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5307
Practice Address - Country:US
Practice Address - Phone:269-323-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010197871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice