1619497989 NPI number — MRS. MITRA DARICE WAITE DMD, PHD

Table of content: MRS. MITRA DARICE WAITE DMD, PHD (NPI 1619497989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619497989 NPI number — MRS. MITRA DARICE WAITE DMD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAITE
Provider First Name:
MITRA
Provider Middle Name:
DARICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DMD, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ADHAMI
Provider Other First Name:
MITRA
Provider Other Middle Name:
DARICE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD, PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619497989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
728 FLAG CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOVER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35226-4917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-479-8490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 HUGHES RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-864-9571
Provider Business Practice Location Address Fax Number:
866-803-4943
Provider Enumeration Date:
06/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6424 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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