Provider Demographics
NPI:1205356672
Name:WATSON, LYDIA (DDS)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 NE 162ND AVE STE D112
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3008
Mailing Address - Country:US
Mailing Address - Phone:901-356-4616
Mailing Address - Fax:
Practice Address - Street 1:1901 NE 162ND AVE STE D112
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3008
Practice Address - Country:US
Practice Address - Phone:360-726-6107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6075800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist