Provider Demographics
NPI:1588715965
Name:WHITE-GAMBRELL, ROSALYN MAVIS (DDS)
Entity type:Individual
Prefix:
First Name:ROSALYN
Middle Name:MAVIS
Last Name:WHITE-GAMBRELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 N HILLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1923
Mailing Address - Country:US
Mailing Address - Phone:601-483-2820
Mailing Address - Fax:601-483-2820
Practice Address - Street 1:1818 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-527-9307
Practice Address - Fax:601-483-5543
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS203883122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064018Medicaid