Provider Demographics
NPI:1720098908
Name:WILLIAMS, BRADLEY EMMETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:EMMETT
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 1:107 N BROOKS ST
Mailing Address - Street 2:
Mailing Address - City:PELAHATCHIE
Mailing Address - State:MS
Mailing Address - Zip Code:39145-3091
Mailing Address - Country:US
Mailing Address - Phone:601-854-5001
Mailing Address - Fax:601-854-6198
Practice Address - Street 1:107 N BROOKS ST
Practice Address - Street 2:
Practice Address - City:PELAHATCHIE
Practice Address - State:MS
Practice Address - Zip Code:39145-3091
Practice Address - Country:US
Practice Address - Phone:601-854-5001
Practice Address - Fax:601-854-6198
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2698961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660353Medicaid