Healthcare Provider Details

I. General information

NPI: 1710967443
Provider Name (Legal Business Name): ROBERT ADDISON WILLIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E LINCOLN AVE
WELLINGTON KS
67152-3061
US

IV. Provider business mailing address

204 E LINCOLN AVE
WELLINGTON KS
67152-3061
US

V. Phone/Fax

Practice location:
  • Phone: 620-326-6261
  • Fax: 620-326-6172
Mailing address:
  • Phone: 620-326-6261
  • Fax: 620-326-6172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5422
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: