Healthcare Provider Details

I. General information

NPI: 1952576597
Provider Name (Legal Business Name): J FRANKLIN WHIPPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 JONAS STREET
CENTRALIA IL
62801
US

IV. Provider business mailing address

1020 JONAS STREET
CENTRALIA IL
62801
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-1821
  • Fax: 618-532-1915
Mailing address:
  • Phone: 618-532-1821
  • Fax: 618-532-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019013703DENTIST
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021000787ORTHODONTIS
License Number StateIL

VIII. Authorized Official

Name: JOHN FRANKLIN WHIPPS
Title or Position: OWNER PRESIDENT
Credential: DMD
Phone: 618-532-1821