MEDICARE: BLAKE WILLIAMSON

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	1223G0001X	General Practice Dentistry	11940	TX

General Provider Information

NPI Number	:	1992924021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE WILLIAMSON

Provider Business Mailing Address
First Line	:	9550 FOREST LN
Second Line	:	STE 700
City	:	DALLAS
State	:	TX
Zip	:	75243-5905
Country	:	US
Telephone Number	:	214-348-5505
Fax Number	:

Provider Business Practice Location Address
First Line	:	9550 FOREST LN
Second Line	:	STE 700
City	:	DALLAS
State	:	TX
Zip	:	75243-5905
Country	:	US
Telephone Number	:	214-348-5505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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Directions to “ BLAKE WILLIAMSON ” Practice Location

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