Provider Demographics
NPI:1265658124
Name:WILLIAMS, JACK OWEN JR (DDS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:OWEN
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 WOODRUFF AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808
Mailing Address - Country:US
Mailing Address - Phone:562-421-3751
Mailing Address - Fax:562-497-1131
Practice Address - Street 1:3840 WOODRUFF AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808
Practice Address - Country:US
Practice Address - Phone:562-421-3751
Practice Address - Fax:562-497-1131
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist