Healthcare Provider Details

I. General information

NPI: 1770640732
Provider Name (Legal Business Name): OTIS RILEY WASHINGTON JR. D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 MYRON DR
RALEIGH NC
27607-3358
US

IV. Provider business mailing address

2310 MYRON DR
RALEIGH NC
27607-3358
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-9536
  • Fax: 919-782-9962
Mailing address:
  • Phone: 919-782-9536
  • Fax: 919-782-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5884
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: