Provider Demographics
NPI:1396752549
Name:WILLIAMS, SAM OLIVER (DMD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:OLIVER
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 1:3285 HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-2342
Mailing Address - Country:US
Mailing Address - Phone:478-784-1572
Mailing Address - Fax:478-784-7150
Practice Address - Street 1:3285 HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-2342
Practice Address - Country:US
Practice Address - Phone:478-784-1572
Practice Address - Fax:478-784-7150
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008597122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00138091AMedicaid