Provider Demographics
NPI:1114662939
Name:WHETHAM, TAYLOR JEAN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JEAN
Last Name:WHETHAM
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 1:862 S 2400 RD
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66872-9398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7670 PARKER ST
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4247
Practice Address - Country:US
Practice Address - Phone:785-239-4174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3051124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist