Provider Demographics
NPI:1376685982
Name:WILLIAMS, VINCENT L (DMD,PA)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DMD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3314
Mailing Address - Country:US
Mailing Address - Phone:208-734-3562
Mailing Address - Fax:208-736-8339
Practice Address - Street 1:590 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3314
Practice Address - Country:US
Practice Address - Phone:208-734-3562
Practice Address - Fax:208-736-8339
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1658-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805148000Medicaid
ID001226500Medicaid
ID001226600Medicaid
ID001226600Medicaid
T44225Medicare UPIN