Provider Demographics
NPI:1194967844
Name:WATTERSON, GLENN RICHARD (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:RICHARD
Last Name:WATTERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W WASHINGTON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2169
Mailing Address - Country:US
Mailing Address - Phone:517-782-1467
Mailing Address - Fax:517-782-3659
Practice Address - Street 1:306 W WASHINGTON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2169
Practice Address - Country:US
Practice Address - Phone:517-782-1467
Practice Address - Fax:517-782-3659
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010098031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice