Provider Demographics
NPI:1992836209
Name:WHITWORTH, E LEO JR (DDS)
Entity type:Individual
Prefix:DR
First Name:E
Middle Name:LEO
Last Name:WHITWORTH
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:E
Other - Middle Name:LEO
Other - Last Name:WHITWORTH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:542 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-3014
Mailing Address - Country:US
Mailing Address - Phone:617-298-1955
Mailing Address - Fax:617-296-6004
Practice Address - Street 1:542 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-3014
Practice Address - Country:US
Practice Address - Phone:617-298-1955
Practice Address - Fax:617-296-6004
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA135581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice