Healthcare Provider Details

I. General information

NPI: 1285652313
Provider Name (Legal Business Name): LINDA B WHITAKER D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
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: 478-825-7836
Mailing address:
  • Phone: 478-825-2001
  • Fax: 478-825-7836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10065
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: