Provider Demographics
NPI:1700172715
Name:WHITNEY, JACOB C (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 EAST BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063
Mailing Address - Country:US
Mailing Address - Phone:918-245-5979
Mailing Address - Fax:918-245-1245
Practice Address - Street 1:3811 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3603
Practice Address - Country:US
Practice Address - Phone:405-751-7131
Practice Address - Fax:405-751-7160
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK63091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice