Provider Demographics
NPI:1659768596
Name:WILLIAMS, TERRY CHARLES (D D S)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:CHARLES
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17008 E 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7630
Mailing Address - Country:US
Mailing Address - Phone:816-590-2987
Mailing Address - Fax:
Practice Address - Street 1:17008 E 45TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7630
Practice Address - Country:US
Practice Address - Phone:816-590-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992786412OtherUMKC SCHOOL OF DENTISTRY