MEDICARE: WATERTOWN FAMILY DENTAL PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1033640883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERTOWN FAMILY DENTAL PC

Provider Business Mailing Address
First Line	:	190 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-4046
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-4046
Country	:	US
Telephone Number	:	617-923-0233
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PERICHOLE LYN EILERS FURGAL
Credential	:	DDS
Telephone Number	:	617-923-0233

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	03/23/2017

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Directions to “WATERTOWN FAMILY DENTAL PC ” Practice Location

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