Healthcare Provider Details

I. General information

NPI: 1689895658
Provider Name (Legal Business Name): CLINTON ROBERT WATERS JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 CLINTON STREET SUITE 103
WATERTOWN NY
13601-3621
US

IV. Provider business mailing address

108 STAFFORD DRIVE
BLACK RIVER NY
13612-2145
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-0110
  • Fax:
Mailing address:
  • Phone: 315-773-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number27807
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: