Provider Demographics
NPI:1295775450
Name:WATAHA, JOHN C (DMD, PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:WATAHA
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC STREET UNIVERSITY OF WASHINGTON
Mailing Address - Street 2:D779A, BOX 357456, RESTORATIVE DENTISTRY
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7456
Mailing Address - Country:US
Mailing Address - Phone:206-543-5948
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC STREET UNIVERSITY OF WASHINGTON
Practice Address - Street 2:D779A, BOX 357456, RESTORATIVE DENTISTRY
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7456
Practice Address - Country:US
Practice Address - Phone:206-543-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000112031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG0250Medicaid