Healthcare Provider Details

I. General information

NPI: 1609948439
Provider Name (Legal Business Name): CRYSTAL GRACE WATSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. CRYSTAL GRACE MCCLEARY

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 NEW BERN AVENUE NEW BERN RIDGE DENTAL CENTER
RALEIGH NC
27610
US

IV. Provider business mailing address

2168 PERSIMMON RIDGE DRIVE
RALEIGH NC
27604
US

V. Phone/Fax

Practice location:
  • Phone: 919-250-2930
  • Fax: 919-231-8077
Mailing address:
  • Phone: 919-760-3084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8221
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: