Provider Demographics
NPI:1891118428
Name:MICHAEL J. WHITTED DDS PC
Entity Type:Organization
Organization Name:MICHAEL J. WHITTED DDS PC
Other - Org Name:MICHAEL J. WHITTED & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-695-5100
Mailing Address - Street 1:1950 GYORR AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2289
Mailing Address - Country:US
Mailing Address - Phone:847-695-5100
Mailing Address - Fax:847-695-5180
Practice Address - Street 1:1950 GYORR AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2289
Practice Address - Country:US
Practice Address - Phone:847-695-5100
Practice Address - Fax:847-695-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0278851223G0001X
IL019.0261321223G0001X
IL319.0182171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1750393989OtherNPI