Basic Information
| Provider Information | |||||||||
| NPI: | 1336559673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | PATRICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11642 W FLORISSANT AVE | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630336723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148388220 | ||||||||
| FaxNumber: | 3148384007 | ||||||||
| Practice Location | |||||||||
| Address1: | 11642 W FLORISSANT AVE | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630336723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148388220 | ||||||||
| FaxNumber: | 3148384007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2014011362 | MO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1336559673 | 05 | MO | MEDICAID |