Healthcare Provider Details

I. General information

NPI: 1144341595
Provider Name (Legal Business Name): BRUCE DONALD WATERMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5706 BENJAMIN CENTER DR STE 103
TAMPA FL
33634-5262
US

IV. Provider business mailing address

127 KINGSWAY RD SUITE A
BRANDON FL
33510-4605
US

V. Phone/Fax

Practice location:
  • Phone: 813-288-1999
  • Fax: 813-289-4500
Mailing address:
  • Phone: 813-689-8462
  • Fax: 813-684-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN9391
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: