Maxwell Theodore Dismuke, DDS
Individual provider Active NPI Dentist · Redway, CA
NPI 1235098005 · NPPES record last updated Sep 3, 2026
Key facts
- NPI
- 1235098005
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 112497 (CA)
- Practice address
- 217 Briceland Thorn Rd
Redway, CA 95560 - Phone
- (707) 923-2783
- NPI assigned
- Jan 19, 2026
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Dentist
- Education
- Other, 2025
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
1300 National Dr
Suite 135
Sacramento, CA 95834-1947
PO Box
Suite 769
Redway, CA 95560
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260501002118 | CA | Practitioner - Dentist | 7517435142 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 112497 | CA | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist |
122300000X | 112497 | CA | Yes |
Addresses
Primary practice location
217 Briceland Thorn Rd
Redway, CA 95560
Mailing address
PO Box 769
Redway, CA 95560-0769
Phone (707) 923-2783
Other practice location 1
101 West Coast Rd
Redway, CA 95560
Phone (707) 923-2783
Other providers in Redway, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 3, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.