Provider Demographics
NPI:1417164211
Name:WITHERSPOON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WITHERSPOON
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 1:18595 GRAND RIVER AVE
Mailing Address - Street 2:18595 GRANDRIVER AVE.
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2377
Mailing Address - Country:US
Mailing Address - Phone:131-327-0320
Mailing Address - Fax:131-327-0465
Practice Address - Street 1:18595 GRAND RIVER AVE
Practice Address - Street 2:18595 GRANDRIVER AVE.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2377
Practice Address - Country:US
Practice Address - Phone:131-327-0320
Practice Address - Fax:131-327-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist