Provider Demographics
NPI:1457651580
Name:WILLIAMS, JACQUELINE MAXINE (DDS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MAXINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:MAXINE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4 ATLANTIC ST SW
Mailing Address - Street 2:DENTAL OFFICE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-2350
Mailing Address - Country:US
Mailing Address - Phone:202-540-9857
Mailing Address - Fax:202-232-8494
Practice Address - Street 1:4 ATLANTIC ST SW
Practice Address - Street 2:DENTAL OFFICE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2350
Practice Address - Country:US
Practice Address - Phone:202-540-9857
Practice Address - Fax:202-540-9857
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCDEN10011841223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037409300Medicaid