=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982921920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN WHITE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2010
-----------------------------------------------------
Last Update Date | 07/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2868 W MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-249-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2690 BELLA VISTA WAY
-----------------------------------------------------
City | BELLA VISTA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72714-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-855-6764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3780
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 055932-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------