Provider Demographics
NPI:1083756498
Name:WATSON, GORDON LEE JR (DDS INC)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:LEE
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:DDS INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SLEEPY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-1319
Mailing Address - Country:US
Mailing Address - Phone:925-254-9379
Mailing Address - Fax:
Practice Address - Street 1:2150 APPIAN WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2583
Practice Address - Country:US
Practice Address - Phone:510-724-5363
Practice Address - Fax:510-724-5391
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice