Provider Demographics
NPI:1730401605
Name:WATSON ORTHODONTIC SPECIALIST OF THE BRAZOS VALLEY
Entity type:Organization
Organization Name:WATSON ORTHODONTIC SPECIALIST OF THE BRAZOS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARLAND
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:979-776-2114
Mailing Address - Street 1:2400 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2801
Mailing Address - Country:US
Mailing Address - Phone:979-776-2114
Mailing Address - Fax:979-776-5259
Practice Address - Street 1:2400 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2801
Practice Address - Country:US
Practice Address - Phone:979-776-2114
Practice Address - Fax:979-776-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7872261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental