Provider Demographics
NPI:1538262456
Name:WILLES, MICHAEL GLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLEN
Last Name:WILLES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 OAK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2455
Mailing Address - Country:US
Mailing Address - Phone:760-434-5031
Mailing Address - Fax:
Practice Address - Street 1:740 OAK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2455
Practice Address - Country:US
Practice Address - Phone:760-434-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA424481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics