Healthcare Provider Details

I. General information

NPI: 1427495621
Provider Name (Legal Business Name): JENNY MCWILLIAMS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N WEINBACH AVE SUITE 910
EVANSVILLE IN
47711-5990
US

IV. Provider business mailing address

701 N WEINBACH AVE SUITE 910
EVANSVILLE IN
47711-5990
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-2836
  • Fax:
Mailing address:
  • Phone: 812-477-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12006664A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12010009A
License Number StateIN

VIII. Authorized Official

Name: KEN MCWILLIAMS
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-477-2836