Healthcare Provider Details

I. General information

NPI: 1235230731
Provider Name (Legal Business Name): ROBERT DARRELL WHITLEY D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5279 LINCOLN HWY
GAP PA
17527-9427
US

IV. Provider business mailing address

583 CRICKET LN
DOWNINGTOWN PA
19335-4838
US

V. Phone/Fax

Practice location:
  • Phone: 717-442-9537
  • Fax: 717-442-8311
Mailing address:
  • Phone: 610-458-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS021989L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: