Provider Demographics
NPI:1841728755
Name:WILLIAMS, DENNIS DEMETRIUS (MA,ATC,LAT,PES,CES)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:DEMETRIUS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MA,ATC,LAT,PES,CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 MADISON GREEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8321
Mailing Address - Country:US
Mailing Address - Phone:864-525-8821
Mailing Address - Fax:
Practice Address - Street 1:1179 MADISON GREEN DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715
Practice Address - Country:US
Practice Address - Phone:864-525-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC06042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC207PS0010XOtherSPORTS MEDICINE
NC207PS0010XOtherSPORTS MEDICINE