MEDICARE: DANVILLE PEDIATRIC DRE PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1679278790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANVILLE PEDIATRIC DRE PLLC

Provider Business Mailing Address
First Line	:	105 SPRUCE ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40507-2109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4045 RIVERSIDE DR
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-5152
Country	:	US
Telephone Number	:	859-785-8312
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	GREGORY JAMES WHITE
Credential	:	DDS
Telephone Number	:	859-785-8312

Provider Enumeration Date	:	03/31/2023
Last Update Date	:	03/31/2023

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