=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144694878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLEEN WILLIAMS DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2015
-----------------------------------------------------
Last Update Date | 11/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10409 MONTGOMERY PKWY NE STE 202
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-881-8979
-----------------------------------------------------
Fax | 505-888-1003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10409 MONTGOMERY PKWY NE STE 202
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-881-8979
-----------------------------------------------------
Fax | 505-888-1003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MEAH M WASHINGTON
-----------------------------------------------------
Credential | O.M.
-----------------------------------------------------
Telephone | 505-881-8979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD1870
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------