Provider Demographics
NPI:1619040078
Name:SAMUEL E DEATHERAGE DMD PC
Entity Type:Organization
Organization Name:SAMUEL E DEATHERAGE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEATHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:417-926-4910
Mailing Address - Street 1:920 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1315
Mailing Address - Country:US
Mailing Address - Phone:417-926-4910
Mailing Address - Fax:417-926-4399
Practice Address - Street 1:920 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1315
Practice Address - Country:US
Practice Address - Phone:417-926-4910
Practice Address - Fax:417-926-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty