Provider Demographics
NPI:1821420811
Name:GENTRY, DWAYNE (DMD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:GENTRY
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 1:7 MDG
Mailing Address - Street 2:697 LOUISIANA
Mailing Address - City:DYESS AFB
Mailing Address - State:TX
Mailing Address - Zip Code:79607
Mailing Address - Country:US
Mailing Address - Phone:325-696-2304
Mailing Address - Fax:
Practice Address - Street 1:75 MDG DENTAL CLINIC
Practice Address - Street 2:697 LOUISIANA
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:77960
Practice Address - Country:US
Practice Address - Phone:325-696-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT83619819922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist