Provider Demographics
NPI:1568786341
Name:DR WILLIAM WHITE PC
Entity Type:Organization
Organization Name:DR WILLIAM WHITE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-224-1865
Mailing Address - Street 1:225 GOODING ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2442
Mailing Address - Country:US
Mailing Address - Phone:815-224-1865
Mailing Address - Fax:
Practice Address - Street 1:225 GOODING ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2442
Practice Address - Country:US
Practice Address - Phone:815-224-1865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018468122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101268Medicaid
IL1004181Medicaid