Healthcare Provider Details

I. General information

NPI: 1043057334
Provider Name (Legal Business Name): SERENA AUTUMN WATERWORTH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

IV. Provider business mailing address

1268 NE 186TH DR
PORTLAND OR
97230-7127
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5450
  • Fax:
Mailing address:
  • Phone: 503-530-0609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12035
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: