Healthcare Provider Details

I. General information

NPI: 1003341934
Provider Name (Legal Business Name): TREVOR A WILLIAMS DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S GOLD AVE
DEMING NM
88030-4159
US

IV. Provider business mailing address

400 S GOLD AVE
DEMING NM
88030-4159
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-2684
  • Fax: 575-546-1106
Mailing address:
  • Phone: 575-546-2684
  • Fax: 575-546-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD2677
License Number StateNM

VIII. Authorized Official

Name: SAMANTHA K JASSO
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 575-546-2684