Provider Demographics
NPI:1902895303
Name:WATSON, JOHN TODD (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TODD
Last Name:WATSON
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:W134N6605 LILLY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-6058
Mailing Address - Country:US
Mailing Address - Phone:262-252-4161
Mailing Address - Fax:
Practice Address - Street 1:N97W17095 DIVISION RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4606
Practice Address - Country:US
Practice Address - Phone:262-251-5530
Practice Address - Fax:262-251-5613
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3129OtherDENTAL LICENCE #