Healthcare Provider Details

I. General information

NPI: 1568469393
Provider Name (Legal Business Name): RENEE E WATTS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GATEWAY LOOP STE B
SPRINGFIELD OR
97477-1196
US

IV. Provider business mailing address

498 HARLOW RD SUITE 1
SPRINGFIELD OR
97477-1336
US

V. Phone/Fax

Practice location:
  • Phone: 541-465-9821
  • Fax: 541-988-1825
Mailing address:
  • Phone: 541-465-9821
  • Fax: 541-988-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7573
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: