Healthcare Provider Details

I. General information

NPI: 1063650562
Provider Name (Legal Business Name): WHITAKER FAMILY DENTISTRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 ORANGE ST
FORT VALLEY GA
31030-3456
US

IV. Provider business mailing address

906 ORANGE ST
FORT VALLEY GA
31030-3456
US

V. Phone/Fax

Practice location:
  • Phone: 478-825-2001
  • Fax:
Mailing address:
  • Phone: 478-825-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10256
License Number StateGA

VIII. Authorized Official

Name: JOHN G WHITAKER III
Title or Position: OWNER/ DENTIST
Credential:
Phone: 478-825-2001