Provider Demographics
NPI:1275979445
Name:MOSES WATSON III, DDS, PA
Entity Type:Organization
Organization Name:MOSES WATSON III, DDS, PA
Other - Org Name:WATSON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:SHARISSE
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-688-8949
Mailing Address - Street 1:601 FAYETTEVILLE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3910
Mailing Address - Country:US
Mailing Address - Phone:919-688-8949
Mailing Address - Fax:919-688-6068
Practice Address - Street 1:4601 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1815
Practice Address - Country:US
Practice Address - Phone:919-854-0059
Practice Address - Fax:919-854-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998941Medicaid