Provider Demographics
NPI:1972564326
Name:WOMACK, WILLIAM RANDOL (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RANDOL
Last Name:WOMACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 W DEER VALLEY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2107
Mailing Address - Country:US
Mailing Address - Phone:623-572-8855
Mailing Address - Fax:
Practice Address - Street 1:7505 W DEER VALLEY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2107
Practice Address - Country:US
Practice Address - Phone:623-572-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2029687771OtherTAX ID