Provider Demographics
NPI:1447420120
Name:GEORGE E WATTERS III DMD
Entity Type:Organization
Organization Name:GEORGE E WATTERS III DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATTERS III DMD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-652-9843
Mailing Address - Street 1:1212 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101
Mailing Address - Country:US
Mailing Address - Phone:724-652-9843
Mailing Address - Fax:724-652-6577
Practice Address - Street 1:1212 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101
Practice Address - Country:US
Practice Address - Phone:724-652-9843
Practice Address - Fax:724-652-6577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGE E WATTERS III DMD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-10
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018178L1223G0001X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6070430001Medicare NSC