Provider Demographics
NPI:1487616124
Name:WHITE, DENNIS LEE (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:LEE
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W SCENIC RIVERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-2811
Mailing Address - Country:US
Mailing Address - Phone:573-729-4300
Mailing Address - Fax:573-729-4359
Practice Address - Street 1:1100 W SCENIC RIVERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2811
Practice Address - Country:US
Practice Address - Phone:573-729-4300
Practice Address - Fax:573-729-4359
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2200821OtherUNITED HEALTHCARE
MO312683105Medicaid
MO109138OtherBCBS OF MO
2200821OtherUNITED HEALTHCARE
0215840001Medicare NSC
MO312683105Medicaid