Provider Demographics
NPI:1386725984
Name:WATHEN, CHRISTINE STAFFORD (RDH)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:STAFFORD
Last Name:WATHEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 442
Mailing Address - Street 2:HEIDELBERG DENTAL ACTIVITY CREDENTIALS OFFICE
Mailing Address - City:APO AE
Mailing Address - State:NY
Mailing Address - Zip Code:09042
Mailing Address - Country:US
Mailing Address - Phone:605-196-7656
Mailing Address - Fax:
Practice Address - Street 1:CMR 442
Practice Address - Street 2:HEIDELBERG DENTAL ACTIVITY CREDENTIALS OFFICE
Practice Address - City:APO AE
Practice Address - State:NY
Practice Address - Zip Code:09042
Practice Address - Country:US
Practice Address - Phone:605-196-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5196124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist