Provider Demographics
NPI:1528150299
Name:WILLIS, WILLIAM LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
Last Name:WILLIS
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 1:2510 NW KLINE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-672-4899
Mailing Address - Fax:541-957-9907
Practice Address - Street 1:2510 NW KLINE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-672-4899
Practice Address - Fax:541-957-9907
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist