Provider Demographics
NPI:1952462897
Name:WHITTEN, GLADYS JOHNSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLADYS
Middle Name:JOHNSON
Last Name:WHITTEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:GLADYS
Other - Middle Name:JOHNSON
Other - Last Name:WHITTEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 16209
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6209
Mailing Address - Country:US
Mailing Address - Phone:806-535-0238
Mailing Address - Fax:806-794-0025
Practice Address - Street 1:5730 66TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1224
Practice Address - Country:US
Practice Address - Phone:806-535-0238
Practice Address - Fax:806-794-0025
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD11953Medicare ID - Type Unspecified
T14059Medicare UPIN