Provider Demographics
NPI:1285462663
Name:WHITE LAVENDER
Entity type:Organization
Organization Name:WHITE LAVENDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DONLON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-805-3074
Mailing Address - Street 1:7320 ORCHARD LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4756
Mailing Address - Country:US
Mailing Address - Phone:502-805-3074
Mailing Address - Fax:
Practice Address - Street 1:4122 SHELBYVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3212
Practice Address - Country:US
Practice Address - Phone:502-805-3074
Practice Address - Fax:502-251-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial PainGroup - Single Specialty