Basic Information
| Provider Information | |||||||||
| NPI: | 1659944676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14710 E 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990378054 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1222 N PINES RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992064939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099240381 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2021 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE61189593 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.