Provider Demographics
NPI:1104955830
Name:JAMES R WILLIAMSON DMD PC
Entity type:Organization
Organization Name:JAMES R WILLIAMSON DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-921-5100
Mailing Address - Street 1:504 INDIAN TRAIL ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-921-5100
Mailing Address - Fax:770-381-9038
Practice Address - Street 1:504 INDIAN TRAIL ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-921-5100
Practice Address - Fax:770-381-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0078211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508841099Medicare UPIN