Provider Demographics
NPI:1467810143
Name:WILLIAM R. WARREN DDS,PA
Entity Type:Organization
Organization Name:WILLIAM R. WARREN DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RODMAN
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DEGREE
Authorized Official - Phone:336-724-5055
Mailing Address - Street 1:2141 WEST CLEMMONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127
Mailing Address - Country:US
Mailing Address - Phone:336-525-7470
Mailing Address - Fax:336-724-1525
Practice Address - Street 1:1241 W CLEMMONSVILLE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-4790
Practice Address - Country:US
Practice Address - Phone:336-525-7470
Practice Address - Fax:336-724-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4966302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7998929Medicaid