Healthcare Provider Details

I. General information

NPI: 1013325265
Provider Name (Legal Business Name): BRUCE D. WATERMAN, DMD,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 KINGSWAY RD
BRANDON FL
33510-4601
US

IV. Provider business mailing address

127 KINGSWAY RD
BRANDON FL
33510-4601
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-8462
  • Fax: 813-684-5665
Mailing address:
  • Phone: 813-689-8462
  • Fax: 813-684-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN9391
License Number StateFL

VIII. Authorized Official

Name: DR. BRUCE DONALD WATERMAN
Title or Position: PRESIDENT
Credential: DMD
Phone: 813-689-8462