Basic Information
| Provider Information | |||||||||
| NPI: | 1609948439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCLEARY | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2168 PERSIMMON RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197603084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2620 NEW BERN AVENUE | ||||||||
| Address2: | NEW BERN RIDGE DENTAL CENTER | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192502930 | ||||||||
| FaxNumber: | 9192318077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8221 | NC | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5904004 | 05 | NC | MEDICAID | 9027F | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |