Healthcare Provider Details

I. General information

NPI: 1619228897
Provider Name (Legal Business Name): WILLIAMS PLASTIC AND RECONSTRUCTIVE SURGERY,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 PROFESSIONAL CT
DALTON GA
30720-2500
US

IV. Provider business mailing address

1506 PROFESSIONAL CT
DALTON GA
30720-2500
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-2700
  • Fax: 706-278-3444
Mailing address:
  • Phone: 706-278-2700
  • Fax: 706-278-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KLANCY LAUREN OWENS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-278-2700