Provider Demographics
NPI:1558356030
Name:WHITTAKER, JACK ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALLEN
Last Name:WHITTAKER
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 1:422 E TRUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2146
Mailing Address - Country:US
Mailing Address - Phone:419-352-4106
Mailing Address - Fax:419-352-6122
Practice Address - Street 1:960 W WOOSTER ST
Practice Address - Street 2:STE. 201
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2644
Practice Address - Country:US
Practice Address - Phone:419-352-3527
Practice Address - Fax:419-352-6122
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 123691223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0017332Medicaid