=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275979445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSES WATSON III, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2013
-----------------------------------------------------
Last Update Date | 05/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4601 WESTERN BLVD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-854-0059
-----------------------------------------------------
Fax | 919-854-0039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 FAYETTEVILLE ST SUITE 100
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27701-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-688-8949
-----------------------------------------------------
Fax | 919-688-6068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | MS. NICOLE SHARISSE LYONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-688-8949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6184
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------