Provider Demographics
NPI:1649212168
Name:KNODERER, WILLIAM RICHARD (MD , DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RICHARD
Last Name:KNODERER
Suffix:
Gender:M
Credentials:MD , DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:CADDO MILLS
Mailing Address - State:TX
Mailing Address - Zip Code:75135-0222
Mailing Address - Country:US
Mailing Address - Phone:972-772-5596
Mailing Address - Fax:469-698-9804
Practice Address - Street 1:2014 S GOLIAD ST
Practice Address - Street 2:STE 122
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4863
Practice Address - Country:US
Practice Address - Phone:972-722-5596
Practice Address - Fax:469-698-9804
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7885208VP0000X
TX114611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT14229Medicare UPIN
TX00701HMedicare ID - Type Unspecified