Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 0401416986 | VA |
NPI | 1164040044 |
---|---|
Provider Name | Dr. Jeffrey Alan Willis |
First Address | Buffalo, NY 14213-2204 |
Second Address | Buffalo, NY 14214-3001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2020 |
Last Update Date | 08/07/2020 |