Healthcare Provider Details

I. General information

NPI: 1699467548
Provider Name (Legal Business Name): DOMINIQUE WHITE PHDHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DOMINIQUE WILSON-WHITE PHDHP

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 N FRANKLIN ST
PHILADELPHIA PA
19120-3737
US

IV. Provider business mailing address

4821 N FRANKLIN ST
PHILADELPHIA PA
19120-3737
US

V. Phone/Fax

Practice location:
  • Phone: 215-910-5551
  • Fax:
Mailing address:
  • Phone: 215-910-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberPHDH001364
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: