Provider Demographics
NPI:1972611457
Name:WHITE, DERREK (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:DERREK
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2034
Mailing Address - Street 2:
Mailing Address - City:MANCHACA
Mailing Address - State:TX
Mailing Address - Zip Code:78652-2034
Mailing Address - Country:US
Mailing Address - Phone:512-535-0494
Mailing Address - Fax:512-697-9328
Practice Address - Street 1:900 REBEL RD.
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-535-0494
Practice Address - Fax:512-697-9328
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist