Provider Demographics
NPI:1770640732
Name:WASHINGTON, OTIS RILEY JR (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:RILEY
Last Name:WASHINGTON
Suffix:JR
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 MYRON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3358
Mailing Address - Country:US
Mailing Address - Phone:919-782-9536
Mailing Address - Fax:919-782-9962
Practice Address - Street 1:2310 MYRON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3358
Practice Address - Country:US
Practice Address - Phone:919-782-9536
Practice Address - Fax:919-782-9962
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58841223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics