Basic Information
| Provider Information | |||||||||
| NPI: | 1447624465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | LOGISTICS AVE BLDG M4861 | ||||||||
| Address2: | JOEL DENTAL CLINIC MCXC JHC | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | LOGISTICS AVE BLDG M4861 | ||||||||
| Address2: | JOEL DENTAL CLINIC MCXC JHC | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2015 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 31556 | TX | Y | Dental Providers | Dentist |
No ID Information.