Provider Demographics
NPI:1275902298
Name:YEREMI A CANIZALES DDS P A
Entity Type:Organization
Organization Name:YEREMI A CANIZALES DDS P A
Other - Org Name:SEVERN RIVER DENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YEREMI
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CANIZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-647-4094
Mailing Address - Street 1:572 RITCHIE HWY STE F
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2966
Mailing Address - Country:US
Mailing Address - Phone:410-647-4094
Mailing Address - Fax:
Practice Address - Street 1:572 RITCHIE HWY STE F
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2966
Practice Address - Country:US
Practice Address - Phone:410-647-4094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD149331223G0001X
MD148191223P0700X
MD6912124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1790079697OtherNPI