Healthcare Provider Details

I. General information

NPI: 1952584005
Provider Name (Legal Business Name): EDWIN MICHAEL WILLIAMS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL EDWIN WILLIAMS D.D.S.

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HIGHWAY 104
IONE CA
95640
US

IV. Provider business mailing address

4001 HIGHWAY 104 PO BOX 409099
IONE CA
95640
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax:
Mailing address:
  • Phone: 209-274-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: