MEDICARE: WATERTOWN DENTAL HEALTH GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1770653412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERTOWN DENTAL HEALTH GROUP, PC

Provider Business Mailing Address
First Line	:	1131 COMMERCE PARK DR E
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-2279
Country	:	US
Telephone Number	:	315-788-1070
Fax Number	:	315-785-1039

Provider Business Practice Location Address
First Line	:	1131 COMMERCE PARK DR E
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-2279
Country	:	US
Telephone Number	:	315-788-1070
Fax Number	:	315-785-1039

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	MS. PHYLLIS M KELLY
Credential	:
Telephone Number	:	315-788-1070

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	08/22/2020

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