Provider Demographics
NPI:1699467548
Name:WHITE, DOMINIQUE (PHDHP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHDHP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:WILSON-WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHDHP
Mailing Address - Street 1:4821 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-3737
Mailing Address - Country:US
Mailing Address - Phone:215-910-5551
Mailing Address - Fax:
Practice Address - Street 1:4821 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-3737
Practice Address - Country:US
Practice Address - Phone:215-910-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH001364124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist