Healthcare Provider Details

I. General information

NPI: 1144661604
Provider Name (Legal Business Name): KAREN WATANAKEEREE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5371 STATE HIGHWAY 49 N
MARIPOSA CA
95338-9503
US

IV. Provider business mailing address

PO BOX 1209
MARIPOSA CA
95338-1209
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-7788
  • Fax:
Mailing address:
  • Phone: 209-742-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: