Healthcare Provider Details

I. General information

NPI: 1417927286
Provider Name (Legal Business Name): DALE VICKERS WATKINS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-1719
  • Fax: 757-953-0818
Mailing address:
  • Phone: 757-953-1719
  • Fax: 757-953-0818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number0401008205
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: