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General NPI Number Information
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NPI Number | 1780603670
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Entity Type | Individual
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Provider Name | MARK DOUGLAS WATSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 02/15/2017
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Provider Practice Location Address
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Address Line | 1511 PAYNE AVENUE
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City | ST. PAUL
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State | MN
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Zip | 55130
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Country | US
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Telephone | 651-776-2708
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Fax | 651-778-0380
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Provider Business Mailing Address
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Address Line | 1511 PAYNE AVENUE
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City | ST. PAUL
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State | MN
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Zip | 55130
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Country | US
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Telephone | 651-776-2708
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Fax | 651-778-0380
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | MN 8539
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License Number State | MN
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