=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114810991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK WILLIS II DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2025
-----------------------------------------------------
Last Update Date | 05/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2513 REDWINE RD STE C
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-4420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-362-5569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 ROCKAWAY RD
-----------------------------------------------------
City | SENOIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30276-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-362-5569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN123776
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------