Provider Demographics
NPI:1417245929
Name:WILLIAMS, NATHANIEL DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:DAVID
Last Name:WILLIAMS
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 1:1613 FENTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6106122300000X
FLDN235701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist