Healthcare Provider Details

I. General information

NPI: 1073784575
Provider Name (Legal Business Name): JOHNATHAN R. WHITE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8084 W SAHARA AVE STE G
LAS VEGAS NV
89117-1977
US

IV. Provider business mailing address

8084 W SAHARA AVE STE G
LAS VEGAS NV
89117-1977
US

V. Phone/Fax

Practice location:
  • Phone: 702-823-3000
  • Fax: 702-685-8254
Mailing address:
  • Phone: 702-823-3000
  • Fax: 702-685-8254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5556
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: