Provider Demographics
NPI:1649679960
Name:WILLIAM M ODOM, DDS,INC
Entity type:Organization
Organization Name:WILLIAM M ODOM, DDS,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-453-7789
Mailing Address - Street 1:330 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4055
Mailing Address - Country:US
Mailing Address - Phone:760-453-7789
Mailing Address - Fax:760-729-6952
Practice Address - Street 1:5256 S MISSION RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3614
Practice Address - Country:US
Practice Address - Phone:760-453-7789
Practice Address - Fax:760-729-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17850332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7319820001Medicare PIN