Provider Demographics
NPI:1265695787
Name:MICHAEL S. WHITE
Entity type:Organization
Organization Name:MICHAEL S. WHITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDH
Authorized Official - Prefix:
Authorized Official - First Name:TABBATHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-728-3151
Mailing Address - Street 1:446 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79512-6222
Mailing Address - Country:US
Mailing Address - Phone:325-728-3151
Mailing Address - Fax:
Practice Address - Street 1:446 WALNUT ST
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:TX
Practice Address - Zip Code:79512-6222
Practice Address - Country:US
Practice Address - Phone:325-728-3151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009572102Medicaid