Healthcare Provider Details

I. General information

NPI: 1154496297
Provider Name (Legal Business Name): CHARLES ADRIAN WHITE DDS MS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N 34TH
ROGERS AR
72756
US

IV. Provider business mailing address

201 N 34TH ST
ROGERS AR
72756
US

V. Phone/Fax

Practice location:
  • Phone: 479-631-6074
  • Fax: 479-936-8660
Mailing address:
  • Phone: 479-631-6074
  • Fax: 479-936-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberAR2675
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: