Provider Demographics
NPI:1922120336
Name:WATASE, SCOT K (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOT
Middle Name:K
Last Name:WATASE
Suffix:
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 1:505 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3621
Mailing Address - Country:US
Mailing Address - Phone:323-724-1330
Mailing Address - Fax:323-724-4356
Practice Address - Street 1:505 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3621
Practice Address - Country:US
Practice Address - Phone:323-724-1330
Practice Address - Fax:323-724-4356
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry