Provider Demographics
NPI:1679799449
Name:WHISENANT, SAMUEL EDWARD JR (LD DPD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:EDWARD
Last Name:WHISENANT
Suffix:JR
Gender:M
Credentials:LD DPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25052 104TH AVE SE
Mailing Address - Street 2:SUITE G
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6853
Mailing Address - Country:US
Mailing Address - Phone:253-813-8000
Mailing Address - Fax:253-813-8007
Practice Address - Street 1:25052 104TH AVE SE
Practice Address - Street 2:SUITE G
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6853
Practice Address - Country:US
Practice Address - Phone:253-813-8000
Practice Address - Fax:253-813-8007
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000381122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047857OtherPROVIDER