Healthcare Provider Details

I. General information

NPI: 1255626339
Provider Name (Legal Business Name): DANNON WAYNE SUTHERLAND D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE SW JOINT BASE ANACOSTIA
BOLLING AFB DC
20032-7704
US

IV. Provider business mailing address

238 BROOKLEY AVE SW JOINT BASE ANACOSTIA
BOLLING AFB DC
20032-7704
US

V. Phone/Fax

Practice location:
  • Phone: 202-767-5382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5845
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: