Provider Demographics
NPI:1306864434
Name:WHITAKER, JOHN G JR (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:WHITAKER
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3456
Mailing Address - Country:US
Mailing Address - Phone:478-825-2001
Mailing Address - Fax:478-825-7836
Practice Address - Street 1:906 ORANGE ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3456
Practice Address - Country:US
Practice Address - Phone:478-825-2001
Practice Address - Fax:478-825-7836
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA102561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice