Healthcare Provider Details

I. General information

NPI: 1184024630
Provider Name (Legal Business Name): ALBERT WILLIS II D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 HUGHES RD SUITE 6
MADISON AL
35758-8999
US

IV. Provider business mailing address

540 HUGHES RD SUITE 6
MADISON AL
35758-8999
US

V. Phone/Fax

Practice location:
  • Phone: 256-464-7873
  • Fax: 256-464-7864
Mailing address:
  • Phone: 256-464-7873
  • Fax: 256-464-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number16039
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: