Provider Demographics
NPI:1255762142
Name:DYETT, MAXINE COLEMAN
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:COLEMAN
Last Name:DYETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-5100
Mailing Address - Country:US
Mailing Address - Phone:443-858-2495
Mailing Address - Fax:
Practice Address - Street 1:605 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-5100
Practice Address - Country:US
Practice Address - Phone:443-858-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1744P3200X1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management