Provider Demographics
NPI:1437323839
Name:WATERHOUSE FAMILY DENTAL, INC.
Entity Type:Organization
Organization Name:WATERHOUSE FAMILY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:FOTOUHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-614-0454
Mailing Address - Street 1:16055 SW REGATTA LN
Mailing Address - Street 2:STE 800
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-8303
Mailing Address - Country:US
Mailing Address - Phone:503-614-0454
Mailing Address - Fax:503-614-9874
Practice Address - Street 1:16055 SW REGATTA LN
Practice Address - Street 2:STE 800
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8303
Practice Address - Country:US
Practice Address - Phone:503-614-0454
Practice Address - Fax:503-614-9874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty