MEDICARE: PRISCILLA ANTONNIETTE WATT RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	11867	MA

General Provider Information

NPI Number	:	1841291283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISCILLA ANTONNIETTE WATT RDH

Provider Business Mailing Address
First Line	:	941 MINNEAPOLIS DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-1504
Country	:	US
Telephone Number	:	757-474-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	941 MINNEAPOLIS DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-1504
Country	:	US
Telephone Number	:	757-474-9288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/08/2007

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