Provider Demographics
NPI:1568425874
Name:WHITAKER, JOEL R (DDS)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:R
Last Name:WHITAKER
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 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:75 SPY ROCK LOOP ROAD
Practice Address - Street 2:
Practice Address - City:LOOKOUT
Practice Address - State:WV
Practice Address - Zip Code:25868
Practice Address - Country:US
Practice Address - Phone:304-574-2076
Practice Address - Fax:304-574-1068
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0357662Medicaid
WV0136147000Medicaid