Provider Demographics
NPI:1891776845
Name:WHITE, CLARICE RENA (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARICE
Middle Name:RENA
Last Name:WHITE
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 1:12173 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MASON
Mailing Address - State:TN
Mailing Address - Zip Code:38049-7054
Mailing Address - Country:US
Mailing Address - Phone:901-294-2634
Mailing Address - Fax:901-294-2639
Practice Address - Street 1:12173 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:TN
Practice Address - Zip Code:38049-7054
Practice Address - Country:US
Practice Address - Phone:901-294-2634
Practice Address - Fax:901-294-2639
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNML0000008122246RM2200X
TNDS00000050881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225798Medicaid
TN4777OtherDORAL DENTAL
TN4098095OtherBLUECROSS BLUESHIELD
TN3205221Medicaid
TNDS005088OtherLICENSE
TNU78544Medicare UPIN