MEDICARE: DR. DENISE MARIE WALTHOUR D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D6649	OR

General Provider Information

NPI Number	:	1750375069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENISE MARIE WALTHOUR D.M.D.

Provider Business Mailing Address
First Line	:	3505 SE 36TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1862
Country	:	US
Telephone Number	:	503-235-7181
Fax Number	:	503-235-4909

Provider Business Practice Location Address
First Line	:	3505 SE 36TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1862
Country	:	US
Telephone Number	:	503-235-7181
Fax Number	:	503-235-4909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	07/08/2007

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