Provider Demographics
NPI:1114029170
Name:STATEN, WILLIAM S (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:STATEN
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 1:107 W INDIAN CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5276
Mailing Address - Country:US
Mailing Address - Phone:561-630-5730
Mailing Address - Fax:
Practice Address - Street 1:1250 SOUTHWINDS DR
Practice Address - Street 2:PBCPH - LANTANA HEALTH CENTER DENTAL CLINIC
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1459
Practice Address - Country:US
Practice Address - Phone:561-547-6811
Practice Address - Fax:561-540-1107
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11165122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0736431-00Medicaid