Provider Demographics
NPI:1689895658
Name:WATERS, CLINTON ROBERT JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:ROBERT
Last Name:WATERS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 STAFFORD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:13612-2145
Mailing Address - Country:US
Mailing Address - Phone:315-773-2255
Mailing Address - Fax:
Practice Address - Street 1:145 CLINTON STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3621
Practice Address - Country:US
Practice Address - Phone:315-782-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics