Provider Demographics
NPI:1417165150
Name:GORDON LEE WATSON,JR.,D.D.S. INC.
Entity Type:Organization
Organization Name:GORDON LEE WATSON,JR.,D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-724-5363
Mailing Address - Street 1:2150 APPIAN WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2520
Mailing Address - Country:US
Mailing Address - Phone:510-724-5363
Mailing Address - Fax:510-724-5391
Practice Address - Street 1:2150 APPIAN WAY STE 205
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2520
Practice Address - Country:US
Practice Address - Phone:510-724-5363
Practice Address - Fax:510-724-5391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty