Provider Demographics
NPI:1730195892
Name:WILLIAMS, JACK LAWRENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LAWRENCE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5150 E STOP 11 RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8628
Mailing Address - Country:US
Mailing Address - Phone:317-889-6000
Mailing Address - Fax:317-889-1618
Practice Address - Street 1:5150 E STOP 11 RD
Practice Address - Street 2:SUITE 11
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8628
Practice Address - Country:US
Practice Address - Phone:317-889-6000
Practice Address - Fax:317-889-1618
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice