Provider Demographics
NPI:1932110103
Name:WHITE, HEIDI KNIGHT (DMD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:KNIGHT
Last Name:WHITE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:HEIDI
Other - Middle Name:LORRAINE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:709 PETERSON AVE N
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4911
Mailing Address - Country:US
Mailing Address - Phone:912-384-0403
Mailing Address - Fax:912-260-3188
Practice Address - Street 1:709 PETERSON AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4911
Practice Address - Country:US
Practice Address - Phone:912-384-0403
Practice Address - Fax:912-260-3188
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA908126389KMedicaid