Provider Demographics
NPI:1790784338
Name:ODOM, WILLIAM S JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:S
Last Name:ODOM
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:424 9TH ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2895
Mailing Address - Country:US
Mailing Address - Phone:706-327-9936
Mailing Address - Fax:
Practice Address - Street 1:424 9TH ST
Practice Address - Street 2:SUITE #1
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2895
Practice Address - Country:US
Practice Address - Phone:706-327-9936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-16
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
9181476OtherWELLCARE-DORAL
820713OtherUNITED CONCORDIA
GA00318029AMedicaid
100661OtherPEACHSTATE-AVESIS