1477705465 NPI number — JACQUES R. WILLIAMS DDS PC

Table of content: (NPI 1477705465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477705465 NPI number — JACQUES R. WILLIAMS DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUES R. WILLIAMS DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UPTOWN DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477705465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8415 CAMPBELLTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30134-1876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-942-4899
Provider Business Mailing Address Fax Number:
770-942-4859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8415 CAMPBELLTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-1876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-942-4899
Provider Business Practice Location Address Fax Number:
770-942-4859
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JACQUES
Authorized Official Middle Name:
RAMONE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-942-4899

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  DN013290 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 27000355 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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