Provider Demographics
NPI:1609959618
Name:GILLAM, WILLIAM AUSTIN III (DDS)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:AUSTIN
Last Name:GILLAM
Suffix:III
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 1:421 WEST OSAGE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-1332
Mailing Address - Country:US
Mailing Address - Phone:636-257-5515
Mailing Address - Fax:636-257-4433
Practice Address - Street 1:421 WEST OSAGE
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069-1332
Practice Address - Country:US
Practice Address - Phone:636-257-5515
Practice Address - Fax:636-257-4433
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0143411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice