Provider Demographics
NPI:1851564579
Name:JACK A. WHITTAKER D.D.S., INC.
Entity Type:Organization
Organization Name:JACK A. WHITTAKER D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WHITTAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-352-3527
Mailing Address - Street 1:960 W WOOSTER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2644
Mailing Address - Country:US
Mailing Address - Phone:419-352-3527
Mailing Address - Fax:419-352-6122
Practice Address - Street 1:960 W WOOSTER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2644
Practice Address - Country:US
Practice Address - Phone:419-352-3527
Practice Address - Fax:419-352-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30 012369122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0017332Medicaid
OH7073OtherDORAL DENTAL SERVICES
OH01928OtherPARAMOUNT ADVANTAGE