Basic Information
| Provider Information | |||||||||
| NPI: | 1386799880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | WAYLAND | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 411145 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329411145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215913300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1389 S PATRICK DR | ||||||||
| Address2: | BLDG 1371 | ||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329253607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214946366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN14963 | FL | Y | Dental Providers | Dentist | General Practice |
No ID Information.