Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D6926 | AZ |
N | 1223G0001X | General Practice | 3279-03 | MS |
N | 213EG0000X | General Practice | 3279-03 | MS |
NPI | 1013016104 |
---|---|
Provider Name | Sheldon Willis |
First Address | Flowood, MS 39232-7620 |
Second Address | Flowood, MS 39232-7620 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 28/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04350504 | (05) | MS |