Provider Demographics
NPI:1952089609
Name:WHITEHEAD, CORDARYL LEE
Entity Type:Individual
Prefix:DR
First Name:CORDARYL
Middle Name:LEE
Last Name:WHITEHEAD
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 1:9743 WATERSHED DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32220-0903
Mailing Address - Country:US
Mailing Address - Phone:205-496-2310
Mailing Address - Fax:
Practice Address - Street 1:12517 YELLOW BLUFF RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-3809
Practice Address - Country:US
Practice Address - Phone:904-204-7496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN283511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice