Healthcare Provider Details

I. General information

NPI: 1043229917
Provider Name (Legal Business Name): MICHAEL TODD WATKINS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 S. MAIN ST. SUITE A
KENT CITY MI
49330
US

IV. Provider business mailing address

52 S. MAIN ST. P.O. BOX 300
KENT CITY MI
49330
US

V. Phone/Fax

Practice location:
  • Phone: 616-678-4040
  • Fax: 616-678-5194
Mailing address:
  • Phone: 616-678-4040
  • Fax: 616-678-5194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901014777
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: