Provider Demographics
NPI:1831286210
Name:WHITAKER, KELVIN SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:SCOTT
Last Name:WHITAKER
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 1:1215 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4306
Mailing Address - Country:US
Mailing Address - Phone:256-353-1481
Mailing Address - Fax:
Practice Address - Street 1:1215 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4306
Practice Address - Country:US
Practice Address - Phone:256-353-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL49651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
51514998 WHIOtherBLUE CROSS BLUE SHIELD
AL02565Medicare UPIN