Provider Demographics
NPI:1992852081
Name:WHITE, MAE T (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:MAE
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 FAIRBURN RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5038
Mailing Address - Country:US
Mailing Address - Phone:404-349-4343
Mailing Address - Fax:404-349-4344
Practice Address - Street 1:2291 FAIRBURN RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5038
Practice Address - Country:US
Practice Address - Phone:404-349-4343
Practice Address - Fax:404-349-4344
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2017-01-26
Deactivation Date:2016-11-21
Deactivation Code:
Reactivation Date:2017-01-26
Provider Licenses
StateLicense IDTaxonomies
GA84671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000163127AMedicaid
GA9182324Medicaid
GA101112Medicaid