Provider Demographics
NPI:1649344771
Name:WATKINS, GARY LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
Last Name:WATKINS
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 1:2624 S ROWEN
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-6271
Mailing Address - Country:US
Mailing Address - Phone:480-924-7959
Mailing Address - Fax:
Practice Address - Street 1:20280 N 59TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6846
Practice Address - Country:US
Practice Address - Phone:623-748-7299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4446122300000X
AZAZD044461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167032Medicaid
NM64409236Medicaid