Provider Demographics
NPI:1194704171
Name:WHITTAKER, THOMAS C (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
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 1:939 E EMERALD AVE
Mailing Address - Street 2:STE 501
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917
Mailing Address - Country:US
Mailing Address - Phone:865-522-6885
Mailing Address - Fax:865-522-0026
Practice Address - Street 1:939 E EMERALD AVE
Practice Address - Street 2:STE 501
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917
Practice Address - Country:US
Practice Address - Phone:865-522-6885
Practice Address - Fax:865-522-0026
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS02991204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3223817Medicaid
TN3223817Medicaid
T74293Medicare UPIN