Provider Demographics
NPI:1205816253
Name:WATSON, KEITH EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:WATSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 N LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5662
Mailing Address - Country:US
Mailing Address - Phone:503-235-3002
Mailing Address - Fax:503-235-0084
Practice Address - Street 1:1832 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5662
Practice Address - Country:US
Practice Address - Phone:503-235-3002
Practice Address - Fax:503-235-0084
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD82201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice