Provider Demographics
NPI:1942043427
Name:WILLIS, MATTHEW W (DMD, MA)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DMD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19805 N 63RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6901
Mailing Address - Country:US
Mailing Address - Phone:480-721-5943
Mailing Address - Fax:
Practice Address - Street 1:98-1005 MOANALUA RD SPC 2000
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4700
Practice Address - Country:US
Practice Address - Phone:808-489-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-31731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice