Healthcare Provider Details

I. General information

NPI: 1275902298
Provider Name (Legal Business Name): YEREMI A CANIZALES DDS P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 RITCHIE HWY STE F
SEVERNA PARK MD
21146-2966
US

IV. Provider business mailing address

572 RITCHIE HWY STE F
SEVERNA PARK MD
21146-2966
US

V. Phone/Fax

Practice location:
  • Phone: 410-647-4094
  • Fax:
Mailing address:
  • Phone: 410-647-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14933
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number14819
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6912
License Number StateMD

VIII. Authorized Official

Name: YEREMI ANTONIO CANIZALES
Title or Position: OWNER
Credential: DDS
Phone: 410-647-4094