Active NPI
Glenn Richard Watterson, DDS
- General Practice Dentistry
- Jackson, MI
National Provider Identifier
1194967844
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 2901009803
- Practice address
- 306 W Washington Ave
Suite 204
Jackson, MI 49201-2169 - Phone
- (517) 782-1467
- Fax
- (517) 782-3659
- NPI assigned
- Mar 26, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 2901009803 | MI | Primary |
Addresses
Primary practice location
306 W Washington Ave
Suite 204
Jackson, MI 49201-2169
Mailing address
306 W Washington Ave
Suite 204
Jackson, MI 49201-2169
Phone (517) 782-1467
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2901009803 | MI | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1238025600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1238025600000",
"number": "1194967844",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "306 W WASHINGTON AVE",
"address_2": "SUITE 204",
"city": "JACKSON",
"state": "MI",
"postal_code": "492012169",
"telephone_number": "517-782-1467",
"fax_number": "517-782-3659"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "306 W WASHINGTON AVE",
"address_2": "SUITE 204",
"city": "JACKSON",
"state": "MI",
"postal_code": "492012169",
"telephone_number": "517-782-1467",
"fax_number": "517-782-3659"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WATTERSON",
"first_name": "GLENN",
"middle_name": "RICHARD",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-03-26",
"last_updated": "2009-03-26",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MI",
"license": "2901009803",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jackson, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.