1407915655 NPI number — EDWIN M. WHITE AND THOMAS W. HATHORN, A PROFESSIONAL DENTAL CORP.

Table of content: (NPI 1407915655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407915655 NPI number — EDWIN M. WHITE AND THOMAS W. HATHORN, A PROFESSIONAL DENTAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWIN M. WHITE AND THOMAS W. HATHORN, A PROFESSIONAL DENTAL CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WHITE & HATHORN DENTAL CORP.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407915655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 PINEGROVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71360-5726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-448-3804
Provider Business Mailing Address Fax Number:
318-448-4880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 PINEGROVE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71360-5726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-448-3804
Provider Business Practice Location Address Fax Number:
318-448-4880
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HATHORN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
318-448-3804

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3154 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5576 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2775 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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