Provider Demographics
NPI:1912150111
Name:WATERFORD DENTAL SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:WATERFORD DENTAL SPECIALISTS, PLLC
Other - Org Name:WATERFORD DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:254-773-4444
Mailing Address - Street 1:5246 S. 31ST ST.
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502
Mailing Address - Country:US
Mailing Address - Phone:254-773-4444
Mailing Address - Fax:
Practice Address - Street 1:5246 S. 31ST ST.
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502
Practice Address - Country:US
Practice Address - Phone:254-773-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22583261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery