Provider Demographics
NPI:1033359674
Name:WATKINS, IRVIN BRUNO (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:BRUNO
Last Name:WATKINS
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 1:1411 E. 53RD STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4542
Mailing Address - Country:US
Mailing Address - Phone:773-752-1234
Mailing Address - Fax:773-752-4321
Practice Address - Street 1:1411 E. 53RD STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4542
Practice Address - Country:US
Practice Address - Phone:773-752-1234
Practice Address - Fax:773-752-4321
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A147031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice