Provider Demographics
NPI:1093956534
Name:WATTLES, MICHAEL ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:WATTLES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 S 36TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8797
Mailing Address - Country:US
Mailing Address - Phone:479-646-1979
Mailing Address - Fax:479-646-1223
Practice Address - Street 1:8700 S 36TH TER
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8797
Practice Address - Country:US
Practice Address - Phone:479-646-1979
Practice Address - Fax:479-646-1223
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist