Provider Demographics
NPI:1053006296
Name:WILLIAMS, LOREAL (DMD)
Entity type:Individual
Prefix:
First Name:LOREAL
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S POPLAR ST APT 2515
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-0118
Mailing Address - Country:US
Mailing Address - Phone:804-647-9877
Mailing Address - Fax:
Practice Address - Street 1:6316 E INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6953
Practice Address - Country:US
Practice Address - Phone:804-647-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC13460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program