Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 2020022878 | MO |
Y | 1223D0001X | Dental Public Health | 2020022878 | MO |
NPI | 1073122362 |
---|---|
Provider Name | Matthew L Williams |
First Address | Kirksville, MO 63501-2548 |
Second Address | Kirksville, MO 63501-3407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2020 |
Last Update Date | 23/07/2020 |