Provider Demographics
NPI:1790825602
Name:WHITE, KEITH DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DOUGLAS
Last Name:WHITE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-9314
Mailing Address - Country:US
Mailing Address - Phone:910-848-0123
Mailing Address - Fax:910-848-0123
Practice Address - Street 1:2935 BREEZEWOOD AVE
Practice Address - Street 2:SUITE200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5284
Practice Address - Country:US
Practice Address - Phone:910-323-3133
Practice Address - Fax:910-323-9616
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice