Provider Demographics
NPI:1104510049
Name:WATSON, CHRISTIAN (DDS)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
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 1:2649 PEAR ST APT 1
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-3662
Mailing Address - Country:US
Mailing Address - Phone:989-317-6186
Mailing Address - Fax:
Practice Address - Street 1:2074 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3372
Practice Address - Country:US
Practice Address - Phone:541-851-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD117991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500822028Medicaid