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General NPI Number Information
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NPI Number | 1326136326
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Entity Type | Individual
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Provider Name | MARK A WILLIS D.D.S., M.S., P.A.
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Gender | Male
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 1795 RESURGENCE DR
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City | WATKINSVILLE
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State | GA
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Zip | 30677-7306
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Country | US
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Telephone | 479-692-1392
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Fax | 770-982-0005
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Provider Business Mailing Address
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Address Line | 1390 NATCHEZ WAY
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City | GRAYSON
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State | GA
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Zip | 30017-1084
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Country | US
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Telephone | 770-337-1835
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2634
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN015576
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License Number State | GA
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