Provider Demographics
NPI:1144661604
Name:WATANAKEEREE, KAREN (DDS)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:WATANAKEEREE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-1209
Mailing Address - Country:US
Mailing Address - Phone:209-742-7788
Mailing Address - Fax:
Practice Address - Street 1:5371 STATE HIGHWAY 49 N
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9503
Practice Address - Country:US
Practice Address - Phone:209-742-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA63393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1144661604OtherPRIVATE PRACTICE