Healthcare Provider Details

I. General information

NPI: 1073586228
Provider Name (Legal Business Name): T MERRELL WILLIAMS DMD MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 N ARMENIA AVE #101
TAMPA FL
33603
US

IV. Provider business mailing address

4505 N ARMENIA AVE #101
TAMPA FL
33603
US

V. Phone/Fax

Practice location:
  • Phone: 813-354-8707
  • Fax: 813-354-9230
Mailing address:
  • Phone: 813-354-8707
  • Fax: 813-354-9230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN12810
License Number StateFL

VIII. Authorized Official

Name: TODD MERRELL WILLIAMS
Title or Position: OWNER PRESIDENT
Credential: DMD MS
Phone: 813-354-8707