Healthcare Provider Details

I. General information

NPI: 1265421374
Provider Name (Legal Business Name): RICHARD DENNIS WILLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 FORSYTHE AVE
MONROE LA
71201-3608
US

IV. Provider business mailing address

2003 FORSYTHE AVE
MONROE LA
71201-3608
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-2621
  • Fax: 318-388-2835
Mailing address:
  • Phone: 318-388-2621
  • Fax: 318-388-2835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2890
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: