Provider Demographics
NPI:1902219652
Name:WHITAKER, MARY MELODY DAWSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MELODY DAWSON
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 MAIN ST UNIT 253
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3030
Mailing Address - Country:US
Mailing Address - Phone:843-687-7114
Mailing Address - Fax:
Practice Address - Street 1:4303 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566
Practice Address - Country:US
Practice Address - Phone:773-880-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD 8382122300000X
IL019.030440122300000X
SC83821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist