Provider Demographics
NPI:1417155821
Name:WATSON, DAMON OMAR (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:DAMON
Middle Name:OMAR
Last Name:WATSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11545 A NUCKOLS ROAD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5666
Mailing Address - Country:US
Mailing Address - Phone:804-673-8061
Mailing Address - Fax:804-673-5644
Practice Address - Street 1:6031 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2160
Practice Address - Country:US
Practice Address - Phone:804-608-3200
Practice Address - Fax:804-608-3201
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014121321223S0112X
MI29010181531223S0112X
VA0438000245204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901018153OtherDENTAL LICENSE NUMBER