Provider Demographics
NPI:1407015456
Name:WHITE, NICOLE MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:KEMPKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4320 OSAGE BEACH PARKWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065
Mailing Address - Country:US
Mailing Address - Phone:573-348-1466
Mailing Address - Fax:573-348-1581
Practice Address - Street 1:4320 OSAGE BEACH PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065
Practice Address - Country:US
Practice Address - Phone:573-348-1466
Practice Address - Fax:573-348-1581
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080150961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407015456Medicaid
MOFW0919514OtherDEA