Provider Demographics
NPI:1861133365
Name:WHITE, MAYA SIMONE (DDS)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:SIMONE
Last Name:WHITE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MAYA
Other - Middle Name:SIMONE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8179 MCGREGOR XING
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1408
Mailing Address - Country:US
Mailing Address - Phone:662-408-3352
Mailing Address - Fax:
Practice Address - Street 1:8179 MCGREGOR XING
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1408
Practice Address - Country:US
Practice Address - Phone:662-408-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12018122300000X
390200000X
MS4472-24122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program