Provider Demographics
NPI:1982784997
Name:WILLIAMS, JACQUES R (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:R
Last Name:WILLIAMS
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 1:8415 CAMPBELLTON ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1876
Mailing Address - Country:US
Mailing Address - Phone:770-942-4899
Mailing Address - Fax:770-942-4859
Practice Address - Street 1:8415 CAMPBELLTON ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1876
Practice Address - Country:US
Practice Address - Phone:770-942-4899
Practice Address - Fax:770-942-4859
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660354Medicaid