Provider Demographics
NPI:1083673578
Name:WATSON, MICHAEL JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:WATSON
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 1:11810 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127
Mailing Address - Country:US
Mailing Address - Phone:314-842-5000
Mailing Address - Fax:
Practice Address - Street 1:11810 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-0570
Practice Address - Country:US
Practice Address - Phone:314-842-5000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice