Individual
DR. MARK A WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S., M.S., P.A.
Contact information
Practice address
1795 RESURGENCE DR, WATKINSVILLE, GA 30677-7306
(479) 692-1392
(770) 982-0005
Mailing address
1390 NATCHEZ WAY, GRAYSON, GA 30017-1084
(770) 337-1835
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
2634
AR
1223P0221X
Pediatric Dentistry
Primary
DN015576
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100140260A
—
OK
Enumeration date
10/11/2006
Last updated
06/17/2024
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