Provider Demographics
NPI:1952460180
Name:WATERS, TERRELL ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRELL
Middle Name:ANTHONY
Last Name:WATERS
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 1:4300 WHEELER ROAD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-6036
Mailing Address - Country:US
Mailing Address - Phone:202-562-8827
Mailing Address - Fax:202-563-4160
Practice Address - Street 1:4300 WHEELER ROAD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-6036
Practice Address - Country:US
Practice Address - Phone:202-562-8827
Practice Address - Fax:202-563-4160
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN22481223G0001X
MD38291223G0001X
FLDN102331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
104664OtherDORAL