MEDICARE: WILLIE JOE PARKS JR. D.D.S., M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	17107	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306918172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE JOE PARKS JR. D.D.S., M.D.

Provider Business Mailing Address
First Line	:	815 S FLEISHEL AVE
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2017
Country	:	US
Telephone Number	:	903-526-7977
Fax Number	:	903-526-7989

Provider Business Practice Location Address
First Line	:	815 S FLEISHEL AVE
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2017
Country	:	US
Telephone Number	:	903-526-7977
Fax Number	:	903-526-7989

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	03/25/2011

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Directions to “ WILLIE JOE PARKS JR. D.D.S., M.D.” Practice Location

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