Healthcare Provider Details

I. General information

NPI: 1265695787
Provider Name (Legal Business Name): MICHAEL S. WHITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 WALNUT ST
COLORADO CITY TX
79512-6222
US

IV. Provider business mailing address

446 WALNUT ST
COLORADO CITY TX
79512-6222
US

V. Phone/Fax

Practice location:
  • Phone: 325-728-3151
  • Fax:
Mailing address:
  • Phone: 325-728-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19451
License Number StateTX

VIII. Authorized Official

Name: TABBATHA S WHITE
Title or Position: RDH
Credential:
Phone: 325-728-3151