Provider Demographics
NPI:1881843613
Name:TODD WHITLOCK, DDS, LLC
Entity Type:Organization
Organization Name:TODD WHITLOCK, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:WHITLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-332-0052
Mailing Address - Street 1:3671 S SARE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4173
Mailing Address - Country:US
Mailing Address - Phone:812-332-0052
Mailing Address - Fax:812-332-0128
Practice Address - Street 1:3671 S SARE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4173
Practice Address - Country:US
Practice Address - Phone:812-332-0052
Practice Address - Fax:812-332-0128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120091701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty