Provider Demographics
NPI:1376570929
Name:TEDDER, DANIEL SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SAMUEL
Last Name:TEDDER
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 1:124 WAGNER ST
Mailing Address - Street 2:P.O. BOX 921
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-9627
Mailing Address - Country:US
Mailing Address - Phone:704-528-9811
Mailing Address - Fax:
Practice Address - Street 1:124 WAGNER ST
Practice Address - Street 2:124 WAGNER ST.
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-9627
Practice Address - Country:US
Practice Address - Phone:704-528-9811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1048161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice