Provider Demographics
NPI:1376214668
Name:WHITE, NANCY ELLEN (RDH)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
Last Name:WHITE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 GOLD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-8435
Mailing Address - Country:US
Mailing Address - Phone:831-809-1130
Mailing Address - Fax:
Practice Address - Street 1:52 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222-9153
Practice Address - Country:US
Practice Address - Phone:209-754-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20629124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist