Provider Demographics
NPI:1023008364
Name:SUMMERS, DWAYNE GAIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:GAIL
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2583
Mailing Address - Country:US
Mailing Address - Phone:618-453-2353
Mailing Address - Fax:618-453-7020
Practice Address - Street 1:1365 DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2583
Practice Address - Country:US
Practice Address - Phone:618-453-2353
Practice Address - Fax:618-453-7020
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005432Medicaid