MEDICARE: KARLY ELIZABETH WHITSITT DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D14001	MN

General Provider Information

NPI Number	:	1417449141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARLY ELIZABETH WHITSITT DDS

Provider Business Mailing Address
First Line	:	1068 LAKE ST S STE 209
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-2634
Country	:	US
Telephone Number	:	952-220-9925
Fax Number	:

Provider Business Practice Location Address
First Line	:	1068 LAKE ST S STE 209
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-2634
Country	:	US
Telephone Number	:	952-220-9925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2018
Last Update Date	:	05/30/2018

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