Provider Demographics
NPI:1295851558
Name:WHITEFIELD, MARK HERNDON
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:HERNDON
Last Name:WHITEFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LEBANON PIKE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-1206
Mailing Address - Country:US
Mailing Address - Phone:615-889-5545
Mailing Address - Fax:615-665-1066
Practice Address - Street 1:4251 LEBANON PIKE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1206
Practice Address - Country:US
Practice Address - Phone:615-889-5545
Practice Address - Fax:615-665-1066
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice