=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285016154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRADLEY W. WILLIS,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2015
-----------------------------------------------------
Last Update Date | 06/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8161 SEATON PL STE A
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36116-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-260-2929
-----------------------------------------------------
Fax | 334-396-7874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8161 SEATON PL STE A
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36116-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-260-2929
-----------------------------------------------------
Fax | 334-396-7874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADLEY W WILLIS
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 334-260-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4554
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------