Provider Demographics
NPI:1578570784
Name:WATTS, DEREK GENE (DMD, MS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:GENE
Last Name:WATTS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 BLACK GOLD BLVD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2604
Mailing Address - Country:US
Mailing Address - Phone:606-439-0881
Mailing Address - Fax:606-439-1182
Practice Address - Street 1:285 BLACK GOLD BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2604
Practice Address - Country:US
Practice Address - Phone:606-439-0881
Practice Address - Fax:606-439-1182
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60070133Medicaid