Healthcare Provider Details

I. General information

NPI: 1598040156
Provider Name (Legal Business Name): DANA LOUISE WATERBURY RDH EPDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61248 BROOKSWOOD BLVD
BEND OR
97702-2535
US

IV. Provider business mailing address

61248 BROOKSWOOD BLVD
BEND OR
97702-2535
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-8917
  • Fax:
Mailing address:
  • Phone: 541-383-8917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH4127
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: