Provider Demographics
NPI:1225458763
Name:CLEARWHITE DENTAL PLLC
Entity Type:Organization
Organization Name:CLEARWHITE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:JERGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-791-8823
Mailing Address - Street 1:1831 NORTH BELCHER ROAD
Mailing Address - Street 2:SUITE F-3
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1453
Mailing Address - Country:US
Mailing Address - Phone:727-791-8823
Mailing Address - Fax:727-725-4534
Practice Address - Street 1:1831 N BELCHER RD
Practice Address - Street 2:SUITE F-3
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1449
Practice Address - Country:US
Practice Address - Phone:727-791-8823
Practice Address - Fax:727-725-4534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15034261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN15034OtherSTATE DENTAL LICENSE
FLDN15034OtherSTATE DENTAL LICENSE