Healthcare Provider Details

I. General information

NPI: 1720158850
Provider Name (Legal Business Name): GORDON RICHARD WHITE D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2821 N BALLAS RD SUITE 260
SAINT LOUIS MO
63131-2321
US

IV. Provider business mailing address

2821 N BALLAS RD SUITE 260
SAINT LOUIS MO
63131-2321
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-4850
  • Fax: 314-567-5877
Mailing address:
  • Phone: 314-567-4850
  • Fax: 314-567-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number11033
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: