Healthcare Provider Details

I. General information

NPI: 1740239185
Provider Name (Legal Business Name): DAN L WATT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 2ND AVENUE
MELBA ID
83641
US

IV. Provider business mailing address

PO BOX 9 211 16TH AVENUE NORTH
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-1011
  • Fax: 208-495-1012
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-467-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3857
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: