Provider Demographics
NPI:1124116959
Name:WHITEHEAD, MATTHEW TRACY (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TRACY
Last Name:WHITEHEAD
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 1:5213 RUE VERDUN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2349
Mailing Address - Country:US
Mailing Address - Phone:318-445-5489
Mailing Address - Fax:318-445-9915
Practice Address - Street 1:5213 RUE VERDUN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2349
Practice Address - Country:US
Practice Address - Phone:318-445-5489
Practice Address - Fax:318-445-9915
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice