Provider Demographics
NPI:1194810788
Name:WILLIAMS, TANYA JOPHAEL (DDS)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:JOPHAEL
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ROSEMEADE PKWY
Mailing Address - Street 2:APT 1212
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-2976
Mailing Address - Country:US
Mailing Address - Phone:314-330-8096
Mailing Address - Fax:770-892-5969
Practice Address - Street 1:4300 ROSEMEADE PKWY
Practice Address - Street 2:#1212
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-2976
Practice Address - Country:US
Practice Address - Phone:314-330-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012453122300000X
TX0026082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257138953DMedicaid