Provider Demographics
NPI:1730109083
Name:WHITEHOUSE, MICHAEL J (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WHITEHOUSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CENTURY OAKS
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106
Mailing Address - Country:US
Mailing Address - Phone:336-922-9577
Mailing Address - Fax:
Practice Address - Street 1:3020 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4012
Practice Address - Country:US
Practice Address - Phone:336-768-9881
Practice Address - Fax:336-768-6066
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990129Medicaid
U54503Medicare UPIN
2428791Medicare ID - Type Unspecified