Provider Demographics
NPI:1386863629
Name:WILLIAMS, RUSSELL (DMD, MS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 N PAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:IL
Mailing Address - Zip Code:62558-4559
Mailing Address - Country:US
Mailing Address - Phone:217-546-8100
Mailing Address - Fax:
Practice Address - Street 1:3007 SPRING MILL DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6558
Practice Address - Country:US
Practice Address - Phone:217-546-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL687952Medicare PIN