Provider Demographics
NPI:1376800714
Name:WHITESIDES ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:WHITESIDES ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITESIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS , MS
Authorized Official - Phone:941-627-2011
Mailing Address - Street 1:2286 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-3924
Mailing Address - Country:US
Mailing Address - Phone:941-627-2011
Mailing Address - Fax:941-627-6716
Practice Address - Street 1:2286 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3924
Practice Address - Country:US
Practice Address - Phone:941-627-2011
Practice Address - Fax:941-627-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN188141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty