MEDICARE: KAMILI J WILLIS

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	1223G0001X	General Practice Dentistry	DN013181	GA

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

General Provider Information

NPI Number	:	1609841204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMILI J WILLIS

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-546-3333
Fax Number	:	719-546-3334

Provider Business Practice Location Address
First Line	:	3050 MARTIN LUTHER KING JR DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-1500
Country	:	US
Telephone Number	:	404-696-3163
Fax Number	:

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/09/2007

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Directions to “ KAMILI J WILLIS ” Practice Location

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