Provider Demographics
NPI:1972662641
Name:EVERETT, DWAYNE ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:ERIC
Last Name:EVERETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3121
Mailing Address - Country:US
Mailing Address - Phone:410-383-8300
Mailing Address - Fax:410-383-3160
Practice Address - Street 1:1501 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3121
Practice Address - Country:US
Practice Address - Phone:410-383-8300
Practice Address - Fax:410-383-3160
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10227122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD348734200Medicaid