Provider Demographics
NPI:1831577378
Name:LAWRENCE M.WILLIS DDS
Entity type:Organization
Organization Name:LAWRENCE M.WILLIS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-789-1655
Mailing Address - Street 1:3012 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-1529
Mailing Address - Country:US
Mailing Address - Phone:303-789-4165
Mailing Address - Fax:
Practice Address - Street 1:3012 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-1529
Practice Address - Country:US
Practice Address - Phone:303-789-4165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-17
Last Update Date:2015-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2123261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental