Healthcare Provider Details

I. General information

NPI: 1508920919
Provider Name (Legal Business Name): DOUGLAS W WHITE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 N LEROY ST STE F
FENTON MI
48430-2791
US

IV. Provider business mailing address

1535 N LEROY ST STE F
FENTON MI
48430-2791
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-5454
  • Fax: 810-629-8932
Mailing address:
  • Phone: 810-629-5454
  • Fax: 810-629-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11647
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: