Provider Demographics
NPI:1710360870
Name:WEST WATERS DENTAL
Entity Type:Organization
Organization Name:WEST WATERS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:LEVI
Authorized Official - Last Name:TWIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-933-6825
Mailing Address - Street 1:1804 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-1004
Mailing Address - Country:US
Mailing Address - Phone:813-933-6825
Mailing Address - Fax:813-930-7346
Practice Address - Street 1:1804 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-1004
Practice Address - Country:US
Practice Address - Phone:813-933-6825
Practice Address - Fax:813-930-7346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN82911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty