MEDICARE: DR. HENRY B. WOTHUIS D.D.S.

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	4179	OR

General Provider Information

NPI Number	:	1477614113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY B. WOTHUIS D.D.S.

Provider Business Mailing Address
First Line	:	1524 LONG ST
Second Line	:
City	:	SWEET HOME
State	:	OR
Zip	:	97386-2313
Country	:	US
Telephone Number	:	541-367-2931
Fax Number	:	541-367-2935

Provider Business Practice Location Address
First Line	:	1524 LONG ST
Second Line	:
City	:	SWEET HOME
State	:	OR
Zip	:	97386-2313
Country	:	US
Telephone Number	:	541-367-2931
Fax Number	:	541-367-2935

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/08/2007

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