Basic Information
| Provider Information | |||||||||
| NPI: | 1457651580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MAXINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | MAXINE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 ATLANTIC ST SW | ||||||||
| Address2: | DENTAL OFFICE | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200322350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025409857 | ||||||||
| FaxNumber: | 2022328494 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 ATLANTIC ST SW | ||||||||
| Address2: | DENTAL OFFICE | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200322350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025409857 | ||||||||
| FaxNumber: | 2025409857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | DEN1001184 | DC | N | Dental Providers | Dentist | General Practice | 122300000X | DEN1001184 | DC | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 037409300 | 05 | DC | MEDICAID |