Provider Demographics
NPI:1134745227
Name:WHITE, KAYLA (DMD)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 FORUM BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1915
Mailing Address - Country:US
Mailing Address - Phone:573-446-7181
Mailing Address - Fax:573-446-1770
Practice Address - Street 1:1401 FORUM BLVD STE 203
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1915
Practice Address - Country:US
Practice Address - Phone:573-446-7181
Practice Address - Fax:573-446-1770
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200233551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice