Organization
WILLOW DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STACEY L EVANS (MANAGER)
(256) 810-3955
Entity
Organization
Contact information
Practice address
1367 HIGHWAY 72, KILLEN, AL 35645-9136
(256) 757-5313
Mailing address
515 COUNTY ROAD 402, KILLEN, AL 35645-5815
(256) 810-3955
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1003969312
NPI
AL
Enumeration date
11/12/2019
Last updated
11/12/2019
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