Provider Demographics
NPI:1457849960
Name:DENTAL WHITE MANAGEMENT LLC
Entity Type:Organization
Organization Name:DENTAL WHITE MANAGEMENT LLC
Other - Org Name:SEASIDE PERIO CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAYAMPRAKASAM
Authorized Official - Suffix:
Authorized Official - Credentials:BDS,MPH, MS
Authorized Official - Phone:224-877-0645
Mailing Address - Street 1:3680 BEACON AVE APT 320
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-3046
Mailing Address - Country:US
Mailing Address - Phone:224-877-0645
Mailing Address - Fax:669-265-0400
Practice Address - Street 1:43625 MISSION BLVD STE 105
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-5800
Practice Address - Country:US
Practice Address - Phone:669-245-7494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100140261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1215262225Medicaid