Provider Demographics
NPI:1275156499
Name:WATTERSON, LAURA ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELIZABETH
Last Name:WATTERSON
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 1:253 EBONY AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2513
Mailing Address - Country:US
Mailing Address - Phone:307-286-8864
Mailing Address - Fax:
Practice Address - Street 1:1175 MAIN ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2122
Practice Address - Country:US
Practice Address - Phone:760-789-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO.00000005122300000X
CA106041122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist