Provider Demographics
NPI:1881348860
Name:ANDERSON, WHITLEY NICOLE (LD, RAD)
Entity type:Individual
Prefix:
First Name:WHITLEY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LD, RAD
Other - Prefix:MRS
Other - First Name:WHITLEY
Other - Middle Name:NICOLE
Other - Last Name:GAGNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-0549
Mailing Address - Country:US
Mailing Address - Phone:208-642-2310
Mailing Address - Fax:
Practice Address - Street 1:7 GRETCHEN LN
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084
Practice Address - Country:US
Practice Address - Phone:207-642-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDTR5541122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist