Healthcare Provider Details

I. General information

NPI: 1972662641
Provider Name (Legal Business Name): DWAYNE ERIC EVERETT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax: 410-383-3160
Mailing address:
  • Phone: 410-383-8300
  • Fax: 410-383-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10227
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10227
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: