Provider Demographics
NPI:1003859117
Name:DEATHERAGE, JOSEPH RICHARD (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RICHARD
Last Name:DEATHERAGE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 BURNT BOAT DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0886
Mailing Address - Country:US
Mailing Address - Phone:701-258-7220
Mailing Address - Fax:701-222-2329
Practice Address - Street 1:1730 BURNT BOAT DR STE 300
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0886
Practice Address - Country:US
Practice Address - Phone:701-258-7220
Practice Address - Fax:701-222-2329
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2069OtherDENTAL LICENSE
ND41524Medicaid