Provider Demographics
NPI:1497936538
Name:WILLIAMS, DALLAS DEVERE (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:DEVERE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 COUNTRY CLUB PKWY
Mailing Address - Street 2:
Mailing Address - City:MILLIKEN
Mailing Address - State:CO
Mailing Address - Zip Code:80543-9621
Mailing Address - Country:US
Mailing Address - Phone:970-587-5413
Mailing Address - Fax:970-587-5415
Practice Address - Street 1:1952 BLUE MESA CT
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4125
Practice Address - Country:US
Practice Address - Phone:970-635-0400
Practice Address - Fax:970-635-9171
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01407907Medicaid
CO01407907Medicaid