Provider Demographics
NPI:1083674881
Name:WATSON, ETHEL LEA
Entity Type:Individual
Prefix:DR
First Name:ETHEL
Middle Name:LEA
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6828 COMMERCE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2639
Mailing Address - Country:US
Mailing Address - Phone:703-752-2500
Mailing Address - Fax:703-752-2503
Practice Address - Street 1:6828 COMMERCE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2639
Practice Address - Country:US
Practice Address - Phone:703-752-2500
Practice Address - Fax:703-752-2503
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010111463Medicaid