Healthcare Provider Details

I. General information

NPI: 1730109083
Provider Name (Legal Business Name): MICHAEL J WHITEHOUSE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 MAPLEWOOD AVENUE
WINSTON-SALEM NC
27103-4012
US

IV. Provider business mailing address

125 CENTURY OAKS
WINSTON-SALEM NC
27106
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-9881
  • Fax: 336-768-6066
Mailing address:
  • Phone: 336-922-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: