Provider Demographics
NPI:1063835569
Name:WILLHAM, OLIVER LEE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:LEE
Last Name:WILLHAM
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 FLEUR DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-3105
Mailing Address - Country:US
Mailing Address - Phone:515-285-6134
Mailing Address - Fax:515-285-2249
Practice Address - Street 1:7400 FLEUR DR STE 100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-3105
Practice Address - Country:US
Practice Address - Phone:515-285-6134
Practice Address - Fax:515-285-2249
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1578697058Medicaid