Provider Demographics
NPI:1144332321
Name:WHITE, RAYMOND WADE (DD S)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WADE
Last Name:WHITE
Suffix:
Gender:M
Credentials:DD S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CASTLE BUTTE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-8764
Mailing Address - Country:US
Mailing Address - Phone:406-538-3709
Mailing Address - Fax:
Practice Address - Street 1:611 NE MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2020
Practice Address - Country:US
Practice Address - Phone:406-538-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0110045Medicaid