Provider Demographics
NPI:1609948439
Name:WATSON, CRYSTAL GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:GRACE
Last Name:WATSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:GRACE
Other - Last Name:MCCLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2168 PERSIMMON RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604
Mailing Address - Country:US
Mailing Address - Phone:919-760-3084
Mailing Address - Fax:
Practice Address - Street 1:2620 NEW BERN AVENUE
Practice Address - Street 2:NEW BERN RIDGE DENTAL CENTER
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-250-2930
Practice Address - Fax:919-231-8077
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904004Medicaid
NC9027FOtherBLUE CROSS BLUE SHIELD