Provider Demographics
NPI:1194018564
Name:WAITE, TERESA J (LD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:J
Last Name:WAITE
Suffix:
Gender:F
Credentials:LD
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 11470
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-3670
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:
Practice Address - Street 1:2381 NE CONNERS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6068
Practice Address - Country:US
Practice Address - Phone:541-678-6262
Practice Address - Fax:541-516-4039
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10137920122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist