Provider Demographics
NPI:1679622534
Name:WHITTAKER, JOHN MERVYN (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MERVYN
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD STE 203B
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3133
Mailing Address - Country:US
Mailing Address - Phone:909-558-6468
Mailing Address - Fax:
Practice Address - Street 1:25455 BARTON RD STE 203B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3133
Practice Address - Country:US
Practice Address - Phone:909-558-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice