Provider Demographics
NPI:1093499071
Name:WITWER, MAXWELL DRAKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:DRAKE
Last Name:WITWER
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 1:511 N BROAD ST APT 904
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3239
Mailing Address - Country:US
Mailing Address - Phone:717-683-4877
Mailing Address - Fax:
Practice Address - Street 1:2 ATRIUM CT
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9019
Practice Address - Country:US
Practice Address - Phone:570-365-4951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0441411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice