Healthcare Provider Details

I. General information

NPI: 1023472313
Provider Name (Legal Business Name): MARK N. WATERS, D.D.S, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W 21ST ST
CLOVIS NM
88101-4364
US

IV. Provider business mailing address

116 W 21ST ST
CLOVIS NM
88101-4364
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-7632
  • Fax: 575-762-4226
Mailing address:
  • Phone: 575-763-7632
  • Fax: 575-762-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1426
License Number StateNM

VIII. Authorized Official

Name: DR. MARK NEWTON WATERS
Title or Position: PRESIDENT/DENTIST
Credential: D.D.S.
Phone: 575-763-7632