MEDICARE: DR. SALLY R. WILLIS, PSC

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	5032	KY

General Provider Information

NPI Number	:	1710052998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. SALLY R. WILLIS, PSC

Provider Business Mailing Address
First Line	:	7600 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-1729
Country	:	US
Telephone Number	:	502-231-9970
Fax Number	:	502-231-9972

Provider Business Practice Location Address
First Line	:	7600 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-1729
Country	:	US
Telephone Number	:	502-231-9970
Fax Number	:	502-231-9972

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SALLY R. WILLIS
Credential	:	DMD
Telephone Number	:	502-231-9970

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/22/2020

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