Provider Demographics
NPI:1265658751
Name:GWILLIAM, JERRY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:GWILLIAM
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 1:1874 BONANZA ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4318
Mailing Address - Country:US
Mailing Address - Phone:925-935-6080
Mailing Address - Fax:925-935-6084
Practice Address - Street 1:1874 BONANZA ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4318
Practice Address - Country:US
Practice Address - Phone:925-935-6080
Practice Address - Fax:925-935-6084
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA185571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB18557-01Medicare ID - Type Unspecified