Healthcare Provider Details

I. General information

NPI: 1942917240
Provider Name (Legal Business Name): JAMES W WILLIS IV DDS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2927 STUARTS DRAFT HWY STE 105
STUARTS DRAFT VA
24477-2796
US

IV. Provider business mailing address

6948 WELBOURNE LN
CROZET VA
22932-3346
US

V. Phone/Fax

Practice location:
  • Phone: 540-414-8423
  • Fax:
Mailing address:
  • Phone: 304-685-5980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JAMES WILLIS
Title or Position: CEO
Credential: DDS
Phone: 304-685-5980