Provider Demographics
NPI:1033640883
Name:WATERTOWN FAMILY DENTAL PC
Entity Type:Organization
Organization Name:WATERTOWN FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PERICHOLE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:EILERS FURGAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-923-0233
Mailing Address - Street 1:190 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4046
Practice Address - Country:US
Practice Address - Phone:617-923-0233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty