Provider Demographics
NPI:1801991302
Name:THOMAS W WATKINS DDS LLC
Entity type:Organization
Organization Name:THOMAS W WATKINS DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-339-4400
Mailing Address - Street 1:839 S AUTO MALL RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5484
Mailing Address - Country:US
Mailing Address - Phone:812-339-4400
Mailing Address - Fax:812-323-2230
Practice Address - Street 1:839 S AUTO MALL RD
Practice Address - Street 2:SUITE F
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5484
Practice Address - Country:US
Practice Address - Phone:812-339-4400
Practice Address - Fax:812-323-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007821261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental