Provider Demographics
NPI:1891011755
Name:WILLIAMS, JORDAN NATHANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:NATHANIEL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 ELGIN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1923
Mailing Address - Country:US
Mailing Address - Phone:217-836-8467
Mailing Address - Fax:
Practice Address - Street 1:6735 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2112
Practice Address - Country:US
Practice Address - Phone:708-598-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190277011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery