Provider Demographics
NPI:1659543973
Name:WILLIAMS ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:WILLIAMS ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-348-3400
Mailing Address - Street 1:330 E STUMER RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6406
Mailing Address - Country:US
Mailing Address - Phone:605-348-3400
Mailing Address - Fax:605-348-1626
Practice Address - Street 1:330 E STUMER RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6406
Practice Address - Country:US
Practice Address - Phone:605-348-3400
Practice Address - Fax:605-348-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM808261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0003519OtherBLUE CROSS BLUE SHIELD
690846OtherUNITED CONCORDIA
SD8000390Medicaid
0003519OtherBLUE CROSS BLUE SHIELD
690846OtherUNITED CONCORDIA