Provider Demographics
NPI:1992585509
Name:WILLES, TEAGAN (DDS)
Entity type:Individual
Prefix:
First Name:TEAGAN
Middle Name:
Last Name:WILLES
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 1:28188 MOULTON PKWY APT 1612
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7517
Mailing Address - Country:US
Mailing Address - Phone:760-277-1463
Mailing Address - Fax:
Practice Address - Street 1:401 GLENNEYRE ST STE G
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2401
Practice Address - Country:US
Practice Address - Phone:760-277-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist