Provider Demographics
NPI:1134886674
Name:WHITE, CRYSTAL AILANA (RDH, EPDH)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AILANA
Last Name:WHITE
Suffix:
Gender:F
Credentials:RDH, EPDH
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 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13000 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2615
Practice Address - Country:US
Practice Address - Phone:503-259-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8332124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist