Provider Demographics
NPI:1417449141
Name:WHITSITT, KARLY ELIZABETH (DDS)
Entity Type:Individual
Prefix:
First Name:KARLY
Middle Name:ELIZABETH
Last Name:WHITSITT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 LAKE ST S STE 209
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2634
Mailing Address - Country:US
Mailing Address - Phone:952-220-9925
Mailing Address - Fax:
Practice Address - Street 1:1068 LAKE ST S STE 209
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2634
Practice Address - Country:US
Practice Address - Phone:952-220-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND140011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice