Basic Information
| Provider Information | |||||||||
| NPI: | 1669456828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMICHAEL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | BLDG 38717 38 ST. | ||||||||
| Address2: | ATTN: CREDENTIALS OFFICE | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 38717 38 ST. | ||||||||
| Address2: | ATTN: CREDENTIALS OFFICE | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401006643 | VA | Y | Dental Providers | Dentist | General Practice |
No ID Information.