Provider Demographics
NPI:1114376225
Name:WHITE, MARK JR (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-857-4498
Mailing Address - Fax:
Practice Address - Street 1:437 W DEMING PL
Practice Address - Street 2:9TH FLOOR DENTISTRY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3393
Practice Address - Country:US
Practice Address - Phone:312-227-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031419122300000X
IL021.0031261223P0221X
WI1001296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty