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General NPI Number Information
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NPI Number | 1265322432
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Entity Type | Individual
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Provider Name | GRADY DEVAR WATT DDS
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Gender | Male
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Dates
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Enumeration Date | 07/08/2025
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Last Update Date | 07/08/2025
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Provider Practice Location Address
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Address Line | 600 OHIO AVE
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City | CLARKSDALE
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State | MS
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Zip | 38614-6020
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Country | US
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Telephone | 662-624-4292
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 709
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City | SOUTHAVEN
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State | MS
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Zip | 38671-0008
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Country | US
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Telephone | 662-417-1499
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 111356
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License Number State | MS
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