Provider Demographics
NPI:1417268038
Name:WATSON, MALLORI (DMD)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
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 1:3412 E US HIGHWAY 377
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-7418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3412 E US HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-7418
Practice Address - Country:US
Practice Address - Phone:601-466-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056505122300000X
NC9222122300000X
TX41208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist