Provider Demographics
NPI:1639382450
Name:JANE L WATKO DDS PLC
Entity Type:Organization
Organization Name:JANE L WATKO DDS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-353-8860
Mailing Address - Street 1:25994 ELWELL RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-9609
Mailing Address - Country:US
Mailing Address - Phone:586-292-5703
Mailing Address - Fax:
Practice Address - Street 1:20307 W 12 MILE RD
Practice Address - Street 2:STE #106
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5407
Practice Address - Country:US
Practice Address - Phone:248-353-8860
Practice Address - Fax:248-353-8859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4232353Medicaid