Provider Demographics
NPI:1407344294
Name:WILLARDSON, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILLARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 E 21ST ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3544
Mailing Address - Country:US
Mailing Address - Phone:316-684-1470
Mailing Address - Fax:316-684-1470
Practice Address - Street 1:10333 E 21ST ST N STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3544
Practice Address - Country:US
Practice Address - Phone:316-684-1470
Practice Address - Fax:316-684-1470
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200540820BMedicaid