Provider Demographics
NPI:1588439426
Name:WILLIS, EDDIE Q (DMD)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:Q
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MOOTY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-1809
Mailing Address - Country:US
Mailing Address - Phone:706-837-0123
Mailing Address - Fax:706-668-5100
Practice Address - Street 1:313 MOOTY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-1809
Practice Address - Country:US
Practice Address - Phone:706-837-0123
Practice Address - Fax:706-668-5100
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1232071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice