Provider Demographics
NPI:1598027088
Name:WHITTAKER, DIANA JENNY (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:JENNY
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:J
Other - Last Name:LEMIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25630 LITTLE MACK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2109
Mailing Address - Country:US
Mailing Address - Phone:586-285-5758
Mailing Address - Fax:
Practice Address - Street 1:25630 LITTLE MACK AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2109
Practice Address - Country:US
Practice Address - Phone:586-285-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice