Provider Demographics
NPI:1164517017
Name:WHITENER, J D JR (DDS)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:D
Last Name:WHITENER
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MARBLE MILL RD NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1047
Mailing Address - Country:US
Mailing Address - Phone:770-427-8579
Mailing Address - Fax:770-427-8957
Practice Address - Street 1:121 MARBLE MILL RD NW
Practice Address - Street 2:SUITE 201
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1047
Practice Address - Country:US
Practice Address - Phone:770-427-8579
Practice Address - Fax:770-427-8957
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0101911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00305555AMedicaid