Provider Demographics
NPI:1366978272
Name:WILLIAMS, BRAXTON
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5220
Mailing Address - Country:US
Mailing Address - Phone:801-255-5131
Mailing Address - Fax:801-255-5131
Practice Address - Street 1:4323 HILL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:803-751-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10932122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist