Provider Demographics
NPI:1083715387
Name:ETHEL LEA WATSON, D.M.D., M.A.,P.C
Entity type:Organization
Organization Name:ETHEL LEA WATSON, D.M.D., M.A.,P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-752-2500
Mailing Address - Street 1:6828 COMMERCE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2639
Mailing Address - Country:US
Mailing Address - Phone:703-752-2500
Mailing Address - Fax:703-752-2503
Practice Address - Street 1:6828 COMMERCE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2639
Practice Address - Country:US
Practice Address - Phone:703-752-2500
Practice Address - Fax:703-752-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty