Provider Demographics
NPI:1962199448
Name:WATROUS, OLIVIA (DMD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WATROUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 WILLIAMS ST # 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2025
Mailing Address - Country:US
Mailing Address - Phone:203-640-2823
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5888
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:617-432-4258
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program