Healthcare Provider Details

I. General information

NPI: 1689459919
Provider Name (Legal Business Name): KENDRA WHITE HYGENTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 RALPH DAVID ABERNATHY BLVD SW
ATLANTA GA
30310-1716
US

IV. Provider business mailing address

4652 CREEKSIDE VILLAS WAY SE
SMYRNA GA
30082-4895
US

V. Phone/Fax

Practice location:
  • Phone: 404-564-7749
  • Fax:
Mailing address:
  • Phone: 404-495-4734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH010417
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: