Provider Demographics
NPI:1306902929
Name:DISANTIS, WILLIAM S (DD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:DISANTIS
Suffix:
Gender:M
Credentials:DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S 11TH AVE
Mailing Address - Street 2:SUITE #45
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3293
Mailing Address - Country:US
Mailing Address - Phone:509-454-2273
Mailing Address - Fax:509-454-7901
Practice Address - Street 1:210 S 11TH AVE
Practice Address - Street 2:SUITE #45
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3293
Practice Address - Country:US
Practice Address - Phone:509-454-2273
Practice Address - Fax:509-454-7901
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000367122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048293Medicaid
WADN00000367OtherLICENSE NUMBER