Basic Information
| Provider Information | |||||||||
| NPI: | 1760452114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAISON | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT OF THE ARMY, DENTAL ACTIVITY STOP B | ||||||||
| Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103965610 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPT OF THE ARMY, DENTAL ACTIVITY STOP B | ||||||||
| Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103965610 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
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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 | 1223G0001X | 6076 | KY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | BF8904698 | 01 | FEDERAL DEA | OTHER |