Healthcare Provider Details

I. General information

NPI: 1457433427
Provider Name (Legal Business Name): ROBERT L WILLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NONE NONE NONE

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 RIDGECREST DR
MAMMOTH LAKES CA
93546-0101
US

IV. Provider business mailing address

PO BOX 101 PO BOX 101
MAMMOTH LAKES CA
93546-0101
US

V. Phone/Fax

Practice location:
  • Phone: 760-920-0542
  • Fax: 760-111-1111
Mailing address:
  • Phone: 760-992-0054
  • Fax: 760-111-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number032414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: