Provider Demographics
NPI:1528075330
Name:WHITELOCK, GARY H (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:H
Last Name:WHITELOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-2771
Mailing Address - Country:US
Mailing Address - Phone:270-444-6453
Mailing Address - Fax:270-443-8899
Practice Address - Street 1:100 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2771
Practice Address - Country:US
Practice Address - Phone:270-444-6453
Practice Address - Fax:270-443-8899
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice