Healthcare Provider Details

I. General information

NPI: 1194018564
Provider Name (Legal Business Name): TERESA J WAITE LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2381 NE CONNERS AVE
BEND OR
97701-6068
US

IV. Provider business mailing address

PO BOX 11470
EUGENE OR
97440-3670
US

V. Phone/Fax

Practice location:
  • Phone: 541-678-6262
  • Fax: 541-516-4039
Mailing address:
  • Phone: 888-468-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10137920
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: