Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | NM1316 | NM |
NPI | 1013027127 |
---|---|
Provider Name | Dr. Sally Lutrick Waters |
First Address | Ruidoso, NM 88355-0473 |
Second Address | Ruidoso, NM 88345 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 08/07/2007 |