Provider Demographics
NPI:1093855504
Name:WATERMAN, JENNIFER ROSS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSS
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N GREAT NECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4035
Mailing Address - Country:US
Mailing Address - Phone:757-340-8155
Mailing Address - Fax:757-340-8155
Practice Address - Street 1:525 N GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4035
Practice Address - Country:US
Practice Address - Phone:757-340-8155
Practice Address - Fax:757-340-8155
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
201218854Medicare UPIN