Healthcare Provider Details

I. General information

NPI: 1588457097
Provider Name (Legal Business Name): KENDALL RAE WATSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 CAMINO REAL WAY
FORT MYERS FL
33966-1019
US

IV. Provider business mailing address

4312 COASTERRA DR
FORT MYERS FL
33916-8497
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-7400
  • Fax:
Mailing address:
  • Phone: 239-689-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: