Healthcare Provider Details

I. General information

NPI: 1215093018
Provider Name (Legal Business Name): JOHN M WILLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 FUNDY RD
FALMOUTH ME
04105-1705
US

IV. Provider business mailing address

6 FUNDY RD
FALMOUTH ME
04105-1705
US

V. Phone/Fax

Practice location:
  • Phone: 207-781-2272
  • Fax: 207-781-3605
Mailing address:
  • Phone: 207-781-2272
  • Fax: 207-781-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2312
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: