=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952462897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLADYS JOHNSON WHITTEN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 10/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5730 66TH ST SUITE 2
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-535-0238
-----------------------------------------------------
Fax | 806-794-0025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16209
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79490-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-535-0238
-----------------------------------------------------
Fax | 806-794-0025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 11953
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------