Healthcare Provider Details

I. General information

NPI: 1861557100
Provider Name (Legal Business Name): GARY ALAN WHITE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 NE 5TH ST
GRESHAM OR
97030-7308
US

IV. Provider business mailing address

3621 NW 32ND AVE
CAMAS WA
98607-7531
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5484
  • Fax: 503-661-1069
Mailing address:
  • Phone: 360-834-6406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD8787
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: