Healthcare Provider Details

I. General information

NPI: 1700184751
Provider Name (Legal Business Name): RENEE E WATTS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 GATEWAY LOOP STE B
SPRINGFIELD OR
97477-1196
US

IV. Provider business mailing address

1040 GATEWAY LOOP STE B
SPRINGFIELD OR
97477-1196
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 TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7573
License Number StateOR

VIII. Authorized Official

Name: DR. RENEE WATTS
Title or Position: OWNER
Credential: D.D.S.
Phone: 541-465-9821