Provider Demographics
NPI:1568682342
Name:WHITE, DOUGLAS JACK (DMD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JACK
Last Name:WHITE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E FAYETTE ST
Mailing Address - Street 2:P.O. BOX 288
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1949
Mailing Address - Country:US
Mailing Address - Phone:217-285-5553
Mailing Address - Fax:
Practice Address - Street 1:110 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1949
Practice Address - Country:US
Practice Address - Phone:217-285-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice