Provider Demographics
NPI:1023472313
Name:MARK N. WATERS, D.D.S, P.C.
Entity type:Organization
Organization Name:MARK N. WATERS, D.D.S, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:NEWTON
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-763-7632
Mailing Address - Street 1:116 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4364
Mailing Address - Country:US
Mailing Address - Phone:575-763-7632
Mailing Address - Fax:575-762-4226
Practice Address - Street 1:116 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4364
Practice Address - Country:US
Practice Address - Phone:575-763-7632
Practice Address - Fax:575-762-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA794219OtherUNITED CORCORDIA
NM69880832Medicaid