Provider Demographics
NPI:1043229917
Name:WATKINS, MICHAEL TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TODD
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 1:52 S. MAIN ST.
Mailing Address - Street 2:P.O. BOX 300
Mailing Address - City:KENT CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49330
Mailing Address - Country:US
Mailing Address - Phone:616-678-4040
Mailing Address - Fax:616-678-5194
Practice Address - Street 1:52 S. MAIN ST.
Practice Address - Street 2:SUITE A
Practice Address - City:KENT CITY
Practice Address - State:MI
Practice Address - Zip Code:49330
Practice Address - Country:US
Practice Address - Phone:616-678-4040
Practice Address - Fax:616-678-5194
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1825607Medicaid
MI2901014777OtherDENTAL LICENSE ID NUMBER