Provider Demographics
NPI:1184742405
Name:WHITAKER, TIMOTHY WAYNE (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 TALBOTT DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1369
Mailing Address - Country:US
Mailing Address - Phone:270-843-6314
Mailing Address - Fax:270-843-6314
Practice Address - Street 1:1602 WESTEN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4156
Practice Address - Country:US
Practice Address - Phone:270-781-1706
Practice Address - Fax:270-781-2338
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice