Provider Demographics
NPI:1346260387
Name:MYERS, WILLIAM MARK (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:MYERS
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 1:207 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3486
Mailing Address - Country:US
Mailing Address - Phone:270-651-3709
Mailing Address - Fax:270-651-8592
Practice Address - Street 1:207 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3486
Practice Address - Country:US
Practice Address - Phone:270-651-3709
Practice Address - Fax:270-651-8592
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61381223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45605532Medicaid
KY60061389Medicaid