Provider Demographics
NPI:1871638064
Name:WATSON, WAYNE G (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:G
Last Name:WATSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 AZURE COAST DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3508
Mailing Address - Country:US
Mailing Address - Phone:858-455-7144
Mailing Address - Fax:
Practice Address - Street 1:1539 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3641
Practice Address - Country:US
Practice Address - Phone:619-477-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics