Healthcare Provider Details

I. General information

NPI: 1639347958
Provider Name (Legal Business Name): TETSUJI ZENAS WATARI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 E BARNETT RD
MEDFORD OR
97504
US

IV. Provider business mailing address

2930 E BARNETT RD
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-5401
  • Fax: 541-779-8674
Mailing address:
  • Phone: 541-779-5401
  • Fax: 541-779-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD9047
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: