Provider Demographics
NPI:1255762092
Name:WATERMAN FAMILY DENTISTRY
Entity type:Organization
Organization Name:WATERMAN FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIER
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-340-8155
Mailing Address - Street 1:525 N GREAT NECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4035
Mailing Address - Country:US
Mailing Address - Phone:757-340-8155
Mailing Address - Fax:757-340-3919
Practice Address - Street 1:525 N GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4035
Practice Address - Country:US
Practice Address - Phone:757-340-8155
Practice Address - Fax:757-340-3919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty