Provider Demographics
NPI:1881257657
Name:WHITE SMILES PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:WHITE SMILES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-789-7533
Mailing Address - Street 1:787 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2427
Mailing Address - Country:US
Mailing Address - Phone:435-789-7533
Mailing Address - Fax:435-789-7532
Practice Address - Street 1:787 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2427
Practice Address - Country:US
Practice Address - Phone:435-789-7533
Practice Address - Fax:435-789-7532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty