Provider Demographics
NPI:1992314124
Name:WHITSON, EDMUND STUART IV (DMD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:STUART
Last Name:WHITSON
Suffix:IV
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 1:4615 CALLE ARENOSO
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-7915
Mailing Address - Country:US
Mailing Address - Phone:813-784-4542
Mailing Address - Fax:
Practice Address - Street 1:2850 MONROE ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-7656
Practice Address - Country:US
Practice Address - Phone:850-484-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty