Provider Demographics
NPI:1699864322
Name:WILLIS, PAUL JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JAY
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 1:4709 GOLF RD
Mailing Address - Street 2:#1005
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1231
Mailing Address - Country:US
Mailing Address - Phone:847-677-2404
Mailing Address - Fax:847-677-7432
Practice Address - Street 1:4709 GOLF RD
Practice Address - Street 2:#1005
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1231
Practice Address - Country:US
Practice Address - Phone:847-677-2404
Practice Address - Fax:847-677-7432
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1689765679OtherPRACTICE NPI