Provider Demographics
NPI:1124573399
Name:WILLIAMS, DREW JONATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:DREW
Middle Name:JONATHAN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 E MAIN ST
Mailing Address - Street 2:T-1
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-7636
Mailing Address - Country:US
Mailing Address - Phone:505-325-4867
Mailing Address - Fax:
Practice Address - Street 1:3030 E MAIN ST
Practice Address - Street 2:T-1
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-7636
Practice Address - Country:US
Practice Address - Phone:505-325-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist