Provider Demographics
NPI:1477614113
Name:WOTHUIS, HENRY B (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:B
Last Name:WOTHUIS
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 1:1524 LONG ST
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-2313
Mailing Address - Country:US
Mailing Address - Phone:541-367-2931
Mailing Address - Fax:541-367-2935
Practice Address - Street 1:1524 LONG ST
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-2313
Practice Address - Country:US
Practice Address - Phone:541-367-2931
Practice Address - Fax:541-367-2935
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR41791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice