Provider Demographics
NPI:1578697058
Name:WILLHAM ORTHODONTICS
Entity Type:Organization
Organization Name:WILLHAM ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILLHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:515-285-6134
Mailing Address - Street 1:7400 FLEUR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-3104
Mailing Address - Country:US
Mailing Address - Phone:515-285-6134
Mailing Address - Fax:515-285-2249
Practice Address - Street 1:7400 FLEUR
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-3104
Practice Address - Country:US
Practice Address - Phone:515-285-6134
Practice Address - Fax:515-285-2249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA73311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0173054Medicaid