MEDICARE: WILLIAMS SQUARE DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1073051777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAMS SQUARE DENTAL, PLLC

Provider Business Mailing Address
First Line	:	15660 DALLAS PKWY STE 950
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5205 N O'CONNOR BLVD
Second Line	:	SUITE 150
City	:	IRVING
State	:	TX
Zip	:	75039
Country	:	US
Telephone Number	:	972-556-2122
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	AMANDA LIGHTFOOT
Credential	:
Telephone Number	:	254-338-1468

Provider Enumeration Date	:	02/02/2017
Last Update Date	:	01/28/2026

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