Provider Demographics
NPI:1548610702
Name:DERY, DEIADRE A
Entity Type:Individual
Prefix:MRS
First Name:DEIADRE
Middle Name:A
Last Name:DERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 192ND ARMORED TANK BN RD
Mailing Address - Street 2:USA DENTAC HEADQUARTERS BLDG 1022
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5116
Mailing Address - Country:US
Mailing Address - Phone:502-624-6158
Mailing Address - Fax:502-624-2966
Practice Address - Street 1:962 1ST INFATRY DIVISION RD
Practice Address - Street 2:JORDAN DENTAL CLINIC BLDG 2724
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5210
Practice Address - Country:US
Practice Address - Phone:502-626-8301
Practice Address - Fax:502-626-8300
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant