Provider Demographics
NPI:1114141231
Name:WHITLOCK, BOYD OTHO III (DDS, MS, PA)
Entity Type:Individual
Prefix:DR
First Name:BOYD
Middle Name:OTHO
Last Name:WHITLOCK
Suffix:III
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 W HUNTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-7735
Mailing Address - Country:US
Mailing Address - Phone:479-751-1103
Mailing Address - Fax:479-751-3213
Practice Address - Street 1:2890 W HUNTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-7735
Practice Address - Country:US
Practice Address - Phone:479-751-1103
Practice Address - Fax:479-751-3213
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR461386103OtherEIN
71-0737355OtherTAX ID NUMBER