Provider Demographics
NPI:1063650562
Name:WHITAKER FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:WHITAKER FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:478-825-2001
Mailing Address - Street 1:906 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3456
Mailing Address - Country:US
Mailing Address - Phone:478-825-2001
Mailing Address - Fax:
Practice Address - Street 1:906 ORANGE ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3456
Practice Address - Country:US
Practice Address - Phone:478-825-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty