Healthcare Provider Details

I. General information

NPI: 1891135083
Provider Name (Legal Business Name): TERRY L. WATSON DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 HIGHWAY 62 412
ASH FLAT AR
72513-9612
US

IV. Provider business mailing address

1171 HIGHWAY 62 412
ASH FLAT AR
72513-9612
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-7645
  • Fax: 870-994-3566
Mailing address:
  • Phone: 870-994-7645
  • Fax: 870-994-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANA R. WATSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 870-994-7645