Provider Demographics
NPI:1538423942
Name:WHITEHEAD, JOSEPH S (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:196 S MCCLEARY RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-8456
Mailing Address - Country:US
Mailing Address - Phone:816-630-5713
Mailing Address - Fax:641-226-5759
Practice Address - Street 1:196 S MCCLEARY RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-8456
Practice Address - Country:US
Practice Address - Phone:816-630-5713
Practice Address - Fax:641-226-5759
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012021223122300000X, 1223G0001X
IA091641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1538423942Medicaid