MEDICARE: DR. LENA ADELLE WHITE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DGD.10491	SC
2	1223G0001X	General Practice Dentistry	DN123074	GA

General Provider Information

NPI Number	:	1265117519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LENA ADELLE WHITE DMD

Provider Business Mailing Address
First Line	:	PO BOX 8
Second Line	:
City	:	BARTOW
State	:	GA
Zip	:	30413-0008
Country	:	US
Telephone Number	:	912-220-9037
Fax Number	:

Provider Business Practice Location Address
First Line	:	1962 US HIGHWAY 17
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-6463
Country	:	US
Telephone Number	:	912-756-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/15/2023

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