Provider Demographics
NPI:1013579770
Name:ROSS, BETHANY ANN WHITAKER
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:ANN WHITAKER
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 JOHN R RD APT 105
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2569
Mailing Address - Country:US
Mailing Address - Phone:817-781-1524
Mailing Address - Fax:
Practice Address - Street 1:43368 WOODWARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5051
Practice Address - Country:US
Practice Address - Phone:817-781-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist