Provider Demographics
NPI:1578773925
Name:WHITWORTH DENTAL ASSOC
Entity Type:Organization
Organization Name:WHITWORTH DENTAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:E
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:WHITWORTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-298-1955
Mailing Address - Street 1:542 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-3014
Mailing Address - Country:US
Mailing Address - Phone:617-298-1955
Mailing Address - Fax:617-296-6004
Practice Address - Street 1:542 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-3014
Practice Address - Country:US
Practice Address - Phone:617-298-1955
Practice Address - Fax:617-296-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9761829Medicaid