Provider Demographics
NPI:1124917695
Name:WHITESIDES, HARLEY JO
Entity type:Individual
Prefix:
First Name:HARLEY
Middle Name:JO
Last Name:WHITESIDES
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 1:67 N TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2235
Mailing Address - Country:US
Mailing Address - Phone:801-549-8634
Mailing Address - Fax:
Practice Address - Street 1:576 E HIGHWAY 138 STE 200
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-4028
Practice Address - Country:US
Practice Address - Phone:435-728-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14226474-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice