Provider Demographics
NPI:1073686424
Name:DEATHERAGE, SAMUEL E (DMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:DEATHERAGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COLLEGE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2714
Mailing Address - Country:US
Mailing Address - Phone:256-232-0789
Mailing Address - Fax:256-232-5247
Practice Address - Street 1:110 COLLEGE ST
Practice Address - Street 2:SUITE D
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2714
Practice Address - Country:US
Practice Address - Phone:256-232-0789
Practice Address - Fax:256-232-5247
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist