Healthcare Provider Details

I. General information

NPI: 1588982235
Provider Name (Legal Business Name): KEVIN WILLIAMS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 BRAMBLE DR
MONROE LA
71201-2321
US

IV. Provider business mailing address

2710 BRAMBLE DR
MONROE LA
71201-2321
US

V. Phone/Fax

Practice location:
  • Phone: 318-547-6999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3896
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6242
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: