Provider Demographics
NPI:1336703990
Name:WHITE, LANCE ANTHONY
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:ANTHONY
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3709
Mailing Address - Country:US
Mailing Address - Phone:619-451-0610
Mailing Address - Fax:
Practice Address - Street 1:1302 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-3709
Practice Address - Country:US
Practice Address - Phone:619-451-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82300126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant