Provider Demographics
NPI:1396963476
Name:WOOTEN, WILLIAM S (DDS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:WOOTEN
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 1:857 S BECKFORD DR STE F
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-3486
Mailing Address - Country:US
Mailing Address - Phone:252-492-5200
Mailing Address - Fax:252-492-7534
Practice Address - Street 1:857 S BECKFORD DR STE F
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3486
Practice Address - Country:US
Practice Address - Phone:252-492-5200
Practice Address - Fax:252-492-7534
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2410393Medicare ID - Type Unspecified