Provider Demographics
NPI:1407076490
Name:WATKINSON, GLEN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ROBERT
Last Name:WATKINSON
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 1:12 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-1452
Mailing Address - Country:US
Mailing Address - Phone:732-390-6668
Mailing Address - Fax:
Practice Address - Street 1:236 ERNSTON RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1926
Practice Address - Country:US
Practice Address - Phone:732-525-0049
Practice Address - Fax:732-525-0089
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020486031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice