Healthcare Provider Details

I. General information

NPI: 1780935486
Provider Name (Legal Business Name): JARED ANDREW WATTS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 US 1 S
ST AUGUSTINE FL
32086-4233
US

IV. Provider business mailing address

1132 BUCKBEAN BRANCH LN E
SAINT JOHNS FL
32259-4351
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-4833
  • Fax:
Mailing address:
  • Phone: 904-657-9212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN19961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: