Basic Information
Provider Information | |||||||||
NPI: | 1962590604 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | FRANK | ||||||||
MiddleName: | HAVELOOK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3520 NAVIGATOR PT | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379226562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2298547706 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2020 TOWN CENTER BLVD | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379226677 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8652336517 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 06/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 10612 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 010377 | GA | Y |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
ID | Type | State | Issuer | Description | 00806968A | 05 | GA |   | MEDICAID | 1962590604 | 01 | GA | NPPES | OTHER |