Provider Demographics
NPI:1699942532
Name:WILLIS, JOHN L (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
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:PO BOX AD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-1396
Mailing Address - Country:US
Mailing Address - Phone:530-751-3769
Mailing Address - Fax:530-751-1237
Practice Address - Street 1:555 FREMONT ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2534
Practice Address - Country:US
Practice Address - Phone:530-458-5165
Practice Address - Fax:530-458-7830
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice