Provider Demographics
NPI:1396477667
Name:WILLIAMS, DALLAS ODELL
Entity type:Individual
Prefix:MR
First Name:DALLAS
Middle Name:ODELL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 ROBY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-1603
Mailing Address - Country:US
Mailing Address - Phone:814-516-6095
Mailing Address - Fax:
Practice Address - Street 1:6189 ROSALIND RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2324
Practice Address - Country:US
Practice Address - Phone:304-948-5004
Practice Address - Fax:304-948-5068
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist