Healthcare Provider Details

I. General information

NPI: 1356454722
Provider Name (Legal Business Name): JACK ROGER WILLIAMS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23706 MALIBU RD
MALIBU CA
90265
US

IV. Provider business mailing address

23706 MALIBU RD
MALIBU CA
90265
US

V. Phone/Fax

Practice location:
  • Phone: 310-456-6497
  • Fax: 310-456-5902
Mailing address:
  • Phone: 310-456-6497
  • Fax: 310-456-5902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: