Provider Demographics
NPI:1720449630
Name:WHITLOW, CHASE
Entity Type:Individual
Prefix:MR
First Name:CHASE
Middle Name:
Last Name:WHITLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W 24TH ST APT 16E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1349
Mailing Address - Country:US
Mailing Address - Phone:703-674-6899
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE GREEN SHOPPING CTR STE 13
Practice Address - Street 2:
Practice Address - City:BUDD LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07828-1706
Practice Address - Country:US
Practice Address - Phone:973-347-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI027267001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program