Provider Demographics
NPI:1982748554
Name:WHITESIDE, GEORGE LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:LYNN
Last Name:WHITESIDE
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 1:7630 CAMBRIDGE MANOR PL
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3602
Mailing Address - Country:US
Mailing Address - Phone:239-936-3636
Mailing Address - Fax:239-939-1272
Practice Address - Street 1:7630 CAMBRIDGE MANOR PL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3602
Practice Address - Country:US
Practice Address - Phone:239-936-3636
Practice Address - Fax:239-939-1272
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL76311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice