Healthcare Provider Details

I. General information

NPI: 1336197748
Provider Name (Legal Business Name): KATHY LYNN WATERS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 N SCOTTSDALE RD
SCOTTSDALE AZ
85254
US

IV. Provider business mailing address

10630 N SCOTTSDALE RD
SCOTTSDALE AZ
85254
US

V. Phone/Fax

Practice location:
  • Phone: 480-948-3680
  • Fax: 480-948-0711
Mailing address:
  • Phone: 480-948-3680
  • Fax: 480-948-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9070
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: