Provider Demographics
NPI:1508929639
Name:WILLIAMS, THOMAS BRADLEY (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRADLEY
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 1:118 SPRINGHALL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5360
Mailing Address - Country:US
Mailing Address - Phone:843-572-8009
Mailing Address - Fax:843-377-0509
Practice Address - Street 1:118 SPRINGHALL DR
Practice Address - Street 2:SUITE B
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5360
Practice Address - Country:US
Practice Address - Phone:843-572-8009
Practice Address - Fax:843-377-0509
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3808Medicaid
SC1393195OtherUNITED CONCORDIA ID
SCZA9634Medicaid