Provider Demographics
NPI:1164585642
Name:WILLIAMS, DOUGLAS RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RUSSELL
Last Name:WILLIAMS
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 1:3345 RIVER PARK CT NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5288
Mailing Address - Country:US
Mailing Address - Phone:218-751-4216
Mailing Address - Fax:218-444-6057
Practice Address - Street 1:110 4TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3103
Practice Address - Country:US
Practice Address - Phone:218-751-4216
Practice Address - Fax:218-444-6057
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice