Provider Demographics
NPI:1205150406
Name:WHITTET, DOUGLAS LEEROY (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEEROY
Last Name:WHITTET
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 1:1122 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8741
Mailing Address - Country:US
Mailing Address - Phone:208-947-6821
Mailing Address - Fax:
Practice Address - Street 1:1122 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8741
Practice Address - Country:US
Practice Address - Phone:208-947-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCS8544122300000X
ORD6003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist