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General NPI Number Information
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NPI Number | 1780129122
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Entity Type | Organization
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Legal Business Name | WHITE PERIODONTICS & IMPLANT DENTISTRY
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Dates
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Enumeration Date | 12/20/2016
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Last Update Date | 12/20/2016
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Provider Practice Location Address
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Address Line | 440 SOCIETY HILL DR SUITE 201
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City | AIKEN
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State | SC
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Zip | 29803-1754
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Country | US
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Telephone | 864-557-2656
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Fax |
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Provider Business Mailing Address
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Address Line | 440 SOCIETY HILL DR SUITE 201
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City | AIKEN
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State | SC
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Zip | 29803-1754
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DMD
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Name | TYRESIA WHITE
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Credential |
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Telephone | 864-557-2656
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 8701
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License Number State | SC
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