Provider Demographics
NPI:1104832757
Name:DEREK G. WATTS, D.M.D.,M.S.,P.S.C.
Entity Type:Organization
Organization Name:DEREK G. WATTS, D.M.D.,M.S.,P.S.C.
Other - Org Name:HAZARD ORTHODONTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MS
Authorized Official - Phone:606-439-0881
Mailing Address - Street 1:285 BLACK GOLD BLVD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2604
Mailing Address - Country:US
Mailing Address - Phone:606-439-0881
Mailing Address - Fax:606-439-1182
Practice Address - Street 1:285 BLACK GOLD BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2604
Practice Address - Country:US
Practice Address - Phone:606-439-0881
Practice Address - Fax:606-439-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60070133Medicaid