Provider Demographics
NPI:1679660120
Name:WATERMAN, RICHARD TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TODD
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7906
Mailing Address - Country:US
Mailing Address - Phone:970-339-4799
Mailing Address - Fax:
Practice Address - Street 1:5240 W 9TH STREET DR STE 100
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4480
Practice Address - Country:US
Practice Address - Phone:970-353-5262
Practice Address - Fax:970-353-5266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice