Healthcare Provider Details

I. General information

NPI: 1487700704
Provider Name (Legal Business Name): PHILLIP ANDREW WATERMAN JR. DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3748 MONTGOMERY DR
SANTA ROSA CA
95405-5215
US

IV. Provider business mailing address

3748 MONTGOMERY DR
SANTA ROSA CA
95405-5215
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-7905
  • Fax: 707-546-1573
Mailing address:
  • Phone: 707-546-7905
  • Fax: 707-546-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number29520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: