Provider Demographics
NPI:1013027127
Name:WATERS, SALLY LUTRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:LUTRICK
Last Name:WATERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 473
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-0473
Mailing Address - Country:US
Mailing Address - Phone:505-258-3388
Mailing Address - Fax:505-258-4468
Practice Address - Street 1:1098 MECHEM DRIVE
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:505-258-3388
Practice Address - Fax:505-258-4468
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM1316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist