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General NPI Number Information
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NPI Number | 1255762092
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Entity Type | Organization
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Legal Business Name | WATERMAN FAMILY DENTISTRY
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Dates
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Enumeration Date | 12/04/2013
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Last Update Date | 12/04/2013
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Provider Practice Location Address
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Address Line | 525 N GREAT NECK RD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-4035
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Country | US
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Telephone | 757-340-8155
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Fax | 757-340-3919
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Provider Business Mailing Address
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Address Line | 525 N GREAT NECK RD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-4035
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Country | US
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Telephone | 757-340-8155
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Fax | 757-340-3919
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JENNIER ROSS WATERMAN
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Credential | DDS
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Telephone | 757-340-8155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401411099
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License Number State | VA
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