MEDICARE: TERRY A WILLIS D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2219	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043296791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY A WILLIS D.M.D.

Provider Business Mailing Address
First Line	:	127 HUNTS BRIDGE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29617-1623
Country	:	US
Telephone Number	:	864-246-6471
Fax Number	:	864-246-9917

Provider Business Practice Location Address
First Line	:	127 HUNTS BRIDGE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29617-1623
Country	:	US
Telephone Number	:	864-246-6471
Fax Number	:	864-246-9917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	07/08/2007

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