Provider Demographics
NPI:1194749929
Name:MAXWELL, DAVID ROKETHA (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROKETHA
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 DAYBREAK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7261
Mailing Address - Country:US
Mailing Address - Phone:214-771-0167
Mailing Address - Fax:214-771-0167
Practice Address - Street 1:2922B MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215
Practice Address - Country:US
Practice Address - Phone:214-425-2686
Practice Address - Fax:214-426-6813
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130713406Medicaid
QQ04OtherBLUE CROSS BLUE SHIELD
TX18037601Medicaid
TX130713409Medicaid
G60266-01OtherDELTA DENTAL INSURANCE CO