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General NPI Number Information
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NPI Number | 1760697437
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Entity Type | Organization
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Legal Business Name | J.A. WILLIS, DMD AND RUSSELL PARKER, DMD FAMILY DENTISTRY
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/24/2008
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Provider Practice Location Address
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Address Line | 1226 JACKSON AVE
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City | PASCAGOULA
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State | MS
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Zip | 39567-4348
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Country | US
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Telephone | 228-769-9010
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Fax | 228-762-0303
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Provider Business Mailing Address
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Address Line | PO BOX 1086
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City | PASCAGOULA
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State | MS
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Zip | 39568-1086
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Country | US
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Telephone | 228-769-9010
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Fax | 228-762-0303
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Authorized Official
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Title or Position | PARTNER
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Name | DR. J. A. WILLIS
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Credential | DMD
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Telephone | 228-769-9010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1858-79
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License Number State | MS
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