1043057334 NPI number — DR. SERENA AUTUMN WATERWORTH DMD

Table of content: DR. SERENA AUTUMN WATERWORTH DMD (NPI 1043057334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043057334 NPI number — DR. SERENA AUTUMN WATERWORTH DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERWORTH
Provider First Name:
SERENA
Provider Middle Name:
AUTUMN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043057334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1268 NE 186TH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97230-7127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-530-0609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
387 NE 223RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-8554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-491-5450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D12035 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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