Healthcare Provider Details

I. General information

NPI: 1548959323
Provider Name (Legal Business Name): LUCIAN REED WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 HOLLY LN
MANKATO MN
56001-5422
US

IV. Provider business mailing address

1413 N BROAD ST LOWR
MANKATO MN
56001-3222
US

V. Phone/Fax

Practice location:
  • Phone: 336-705-8400
  • Fax:
Mailing address:
  • Phone: 336-705-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15523
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: