Healthcare Provider Details

I. General information

NPI: 1235098005
Provider Name (Legal Business Name): MAXWELL THEODORE DISMUKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 01/19/2026
Certification Date: 01/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 PINE AVE
LONG BEACH CA
90807-1926
US

IV. Provider business mailing address

4220 PINE AVE
LONG BEACH CA
90807-1926
US

V. Phone/Fax

Practice location:
  • Phone: 562-230-6292
  • Fax:
Mailing address:
  • Phone: 562-230-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: