Provider Demographics
NPI:1518057991
Name:WHITEHEAD, DOUGLAS G (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:G
Last Name:WHITEHEAD
Suffix:
Gender:M
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:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-0848
Mailing Address - Country:US
Mailing Address - Phone:260-768-4180
Mailing Address - Fax:260-768-9192
Practice Address - Street 1:2120 N 850 W
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565
Practice Address - Country:US
Practice Address - Phone:260-768-4180
Practice Address - Fax:260-768-9192
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice