Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 16039 | AL |
NPI | 1184024630 |
---|---|
Provider Name | Albert Willis II |
First Address | Madison, AL 35758-8999 |
Second Address | Madison, AL 35758-8999 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2014 |
Last Update Date | 02/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F10242 | (02) | AL |