Provider Demographics
NPI:1962416636
Name:WILLS, JR, GORDON L (DDS)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:WILLS, JR
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 1:266 S CLEVELAND ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3533
Mailing Address - Country:US
Mailing Address - Phone:901-274-3514
Mailing Address - Fax:
Practice Address - Street 1:266 S CLEVELAND ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3533
Practice Address - Country:US
Practice Address - Phone:901-274-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS40461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice