Provider Demographics
NPI:1972639623
Name:WHITMAN, ANASTACIA M (DMD)
Entity type:Individual
Prefix:DR
First Name:ANASTACIA
Middle Name:M
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANASTACIA
Other - Middle Name:M
Other - Last Name:HUNTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4548 N ALBINA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3010
Mailing Address - Country:US
Mailing Address - Phone:503-626-9711
Mailing Address - Fax:
Practice Address - Street 1:4548 N ALBINA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3010
Practice Address - Country:US
Practice Address - Phone:503-626-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA109701223P0221X
ORD89501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR244432Medicaid
OR244432Medicaid