Healthcare Provider Details

I. General information

NPI: 1568425874
Provider Name (Legal Business Name): JOEL R. WHITAKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SPY ROCK LOOP ROAD
LOOKOUT WV
25868
US

IV. Provider business mailing address

PO BOX 337
SCARBRO WV
25917-0337
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-2076
  • Fax: 304-574-1068
Mailing address:
  • Phone: 304-469-2905
  • Fax: 304-465-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2353
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: