Basic Information
Provider Information | |||||||||
NPI: | 1649346321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | CLIFFORD | ||||||||
MiddleName: | DOUGLAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 325 | ||||||||
Address2: |   | ||||||||
City: | DILLINGHAM | ||||||||
State: | AK | ||||||||
PostalCode: | 99576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078425245 | ||||||||
FaxNumber: | 9078429517 | ||||||||
Practice Location | |||||||||
Address1: | 6000 KANAKANAK ROAD | ||||||||
Address2: | MEDICAL STAFF OFFICE | ||||||||
City: | DILLINGHAM | ||||||||
State: | AK | ||||||||
PostalCode: | 99576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078429218 | ||||||||
FaxNumber: | 9078429250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2006 | ||||||||
LastUpdateDate: | 01/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1113 | AK | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | D05912 | 05 | AK |   | MEDICAID |