Provider Demographics
NPI:1245009687
Name:WHITE PALM DENTAL PA
Entity type:Organization
Organization Name:WHITE PALM DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MCGAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-473-6920
Mailing Address - Street 1:2305 VIDINA DR
Mailing Address - Street 2:#103
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8066
Mailing Address - Country:US
Mailing Address - Phone:321-473-6920
Mailing Address - Fax:321-473-6930
Practice Address - Street 1:2305 VIDINA DR
Practice Address - Street 2:#103
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8066
Practice Address - Country:US
Practice Address - Phone:321-473-6920
Practice Address - Fax:321-473-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty