Provider Demographics
NPI:1982835302
Name:WHITAKER, TERENCE J (DMD)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:J
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 N VETERANS PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-0916
Mailing Address - Country:US
Mailing Address - Phone:309-661-0197
Mailing Address - Fax:309-661-0486
Practice Address - Street 1:1507 N VETERANS PKWY STE 2
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0916
Practice Address - Country:US
Practice Address - Phone:309-661-0197
Practice Address - Fax:309-661-0486
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist