Healthcare Provider Details

I. General information

NPI: 1194967844
Provider Name (Legal Business Name): GLENN RICHARD WATTERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W WASHINGTON AVE SUITE 204
JACKSON MI
49201-2169
US

IV. Provider business mailing address

306 W WASHINGTON AVE SUITE 204
JACKSON MI
49201-2169
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-1467
  • Fax: 517-782-3659
Mailing address:
  • Phone: 517-782-1467
  • Fax: 517-782-3659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901009803
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: