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General NPI Number Information
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NPI Number | 1336450675
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Entity Type | Organization
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Legal Business Name | GRAND AVE DENTAL CENTER PLLC
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Dates
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Enumeration Date | 07/01/2010
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Last Update Date | 07/01/2010
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Provider Practice Location Address
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Address Line | 720 W GRAND AVE
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City | CHICKASHA
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State | OK
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Zip | 73018-5743
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Country | US
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Telephone | 405-224-1311
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Fax | 405-222-3654
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Provider Business Mailing Address
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Address Line | 720 W GRAND AVE
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City | CHICKASHA
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State | OK
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Zip | 73018-5743
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Country | US
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Telephone | 405-224-1311
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Fax | 405-222-3654
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Authorized Official
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Title or Position | MEMBER
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Name | DR. GEORGE W. WILLIAMS III
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Credential | DDS
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Telephone | 405-224-1311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6126
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5709
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3609
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License Number State | OK
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