1235448598 NPI number — DR. C.R. WHITE AND ASSOCIATES DENTAL CENTER,INC.

Table of content: (NPI 1235448598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235448598 NPI number — DR. C.R. WHITE AND ASSOCIATES DENTAL CENTER,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. C.R. WHITE AND ASSOCIATES DENTAL CENTER,INC.
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:
Provider Other Organization Name Type Code:
6
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:
1235448598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STANTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38069-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-294-2634
Provider Business Mailing Address Fax Number:
901-294-2639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12173 MAIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38049-7054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-294-2634
Provider Business Practice Location Address Fax Number:
901-294-2639
Provider Enumeration Date:
10/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CLARICE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
901-294-2634

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5088 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3225536 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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