MEDICARE: DILLON GENE WATTS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	DEN.00204754	CO

General Provider Information

NPI Number	:	1053949388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DILLON GENE WATTS DMD

Provider Business Mailing Address
First Line	:	5925 LEHMAN DR STE 2
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3418
Country	:	US
Telephone Number	:	719-284-7315
Fax Number	:

Provider Business Practice Location Address
First Line	:	5925 LEHMAN DR STE 2
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3418
Country	:	US
Telephone Number	:	719-284-7315
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2020
Last Update Date	:	06/25/2021

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