Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 06207 | IA |
NPI | 1326004714 |
---|---|
Provider Name | Dr. Craig Charles Willard |
First Address | Ft Carson, CO 80913-4095 |
Second Address | Ft Carson, CO 80913-4095 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 08/07/2007 |