Provider Demographics
NPI:1316099500
Name:WATSON, KWANE MITCHELL (DMD)
Entity type:Individual
Prefix:DR
First Name:KWANE
Middle Name:MITCHELL
Last Name:WATSON
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5906 WORTHINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8554
Mailing Address - Country:US
Mailing Address - Phone:502-523-2347
Mailing Address - Fax:
Practice Address - Street 1:2500 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1081
Practice Address - Country:US
Practice Address - Phone:502-776-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000072Medicaid