Provider Demographics
NPI:1912179516
Name:WATSON PSC
Entity Type:Organization
Organization Name:WATSON PSC
Other - Org Name:SMILES ON MEETING STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KWANE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-776-1754
Mailing Address - Street 1:10515 MEETING ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-6523
Mailing Address - Country:US
Mailing Address - Phone:502-420-2480
Mailing Address - Fax:502-420-2891
Practice Address - Street 1:10515 MEETING ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-6523
Practice Address - Country:US
Practice Address - Phone:502-420-2480
Practice Address - Fax:502-420-2891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATSON PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900346Medicaid