Provider Demographics
NPI:1497822662
Name:WHITAKER, SCOTT DELANO (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DELANO
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1503
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-236-7888
Mailing Address - Fax:662-236-2025
Practice Address - Street 1:2886 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-236-7888
Practice Address - Fax:662-236-2025
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14210204E00000X
MS263991204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96646Medicare UPIN