Provider Demographics
NPI:1497322440
Name:WHITE, IVY ELLIS
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:ELLIS
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 N HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8958
Mailing Address - Country:US
Mailing Address - Phone:843-856-8856
Mailing Address - Fax:
Practice Address - Street 1:2928 N HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8958
Practice Address - Country:US
Practice Address - Phone:843-856-8856
Practice Address - Fax:843-856-8814
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9913261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9913OtherSOUTH CAROLINA DENTAL LICENSE