Provider Demographics
NPI:1518904259
Name:WILLIAMS, LARRY S (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:115 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3244
Practice Address - Country:US
Practice Address - Phone:573-884-6253
Practice Address - Fax:573-884-5390
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0116741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400904629Medicaid
MOT71013Medicare UPIN
MO400904629Medicaid
MOP00601096Medicare PIN
MO000001412Medicare PIN
MO190006029Medicare PIN