Provider Demographics
NPI:1740239185
Name:WATT, DAN L (DDS)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:L
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:PO BOX 9
Mailing Address - Street 2:211 16TH AVENUE NORTH
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-467-7684
Practice Address - Street 1:150 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:MELBA
Practice Address - State:ID
Practice Address - Zip Code:83641
Practice Address - Country:US
Practice Address - Phone:208-495-1011
Practice Address - Fax:208-495-1012
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCS10865OtherCONTROLLED SUBSTANCE REGI
BW9113680OtherDEA US DEPT OF JUSTICE