Healthcare Provider Details

I. General information

NPI: 1063627982
Provider Name (Legal Business Name): ALAN D. WILLIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 BROADWAY ST
MOUNT VERNON IL
62864-2980
US

IV. Provider business mailing address

13340 BRIDGEFORD AVE
BONITA SPRINGS FL
34135-3489
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-5600
  • Fax:
Mailing address:
  • Phone: 238-495-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19A12643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: