MEDICARE: DR. GEORGE LYNN WHITESIDE 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	7631	FL

General Provider Information

NPI Number	:	1982748554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE LYNN WHITESIDE DDS

Provider Business Mailing Address
First Line	:	7630 CAMBRIDGE MANOR PL
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3602
Country	:	US
Telephone Number	:	239-936-3636
Fax Number	:	239-939-1272

Provider Business Practice Location Address
First Line	:	7630 CAMBRIDGE MANOR PL
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3602
Country	:	US
Telephone Number	:	239-936-3636
Fax Number	:	239-939-1272

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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