Provider Demographics
NPI:1346578689
Name:WILLIAMS, TANYA GAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:GAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 STATESVILLE BLVD.
Mailing Address - Street 2:STE 4
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144
Mailing Address - Country:US
Mailing Address - Phone:704-636-1533
Mailing Address - Fax:704-636-5514
Practice Address - Street 1:644 STATESVILLE BLVD.
Practice Address - Street 2:STE 4
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144
Practice Address - Country:US
Practice Address - Phone:704-636-1533
Practice Address - Fax:704-636-5514
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913473Medicaid