Provider Demographics
NPI:1265571491
Name:WATTERS, GAYLE (DMD)
Entity type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:
Last Name:WATTERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7728 OLD CANTON ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-856-1511
Mailing Address - Fax:601-856-1011
Practice Address - Street 1:7728 OLD CANTON ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-856-1511
Practice Address - Fax:601-856-1011
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS315800122300000X
MS3158-001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660446Medicaid