Provider Demographics
NPI:1487636122
Name:WATT, PHILLIP E (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:E
Last Name:WATT
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 1:2056 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6105
Mailing Address - Country:US
Mailing Address - Phone:307-672-2421
Mailing Address - Fax:
Practice Address - Street 1:2056 S SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6105
Practice Address - Country:US
Practice Address - Phone:307-672-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117446100OtherTITLE 19