Healthcare Provider Details

I. General information

NPI: 1558353482
Provider Name (Legal Business Name): BRADFORD RAYMOND WILLIAMS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 04/03/2006
Reactivation Date: 04/11/2006

III. Provider practice location address

1400 W 4TH ST
SKIATOOK OK
74070-3927
US

IV. Provider business mailing address

PO BOX 1090
SKIATOOK OK
74070-5090
US

V. Phone/Fax

Practice location:
  • Phone: 918-396-3711
  • Fax: 918-396-1062
Mailing address:
  • Phone: 918-396-3711
  • Fax: 918-396-1062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4393
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: