Provider Demographics
NPI:1164684403
Name:WILLIAMS, TYJUAN MARCQUELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYJUAN
Middle Name:MARCQUELL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 JIMMIE DYESS PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9491
Mailing Address - Country:US
Mailing Address - Phone:706-868-4200
Mailing Address - Fax:706-868-4717
Practice Address - Street 1:4045 JIMMIE DYESS PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9491
Practice Address - Country:US
Practice Address - Phone:706-868-4200
Practice Address - Fax:706-868-4717
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107901BMedicaid