Provider Demographics
NPI:1689721813
Name:DEATHERAGE, TED A (DMD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:A
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 1:1616 GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1814
Mailing Address - Country:US
Mailing Address - Phone:417-257-0126
Mailing Address - Fax:417-256-2469
Practice Address - Street 1:1616 GIBSON ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1814
Practice Address - Country:US
Practice Address - Phone:417-257-0126
Practice Address - Fax:417-256-2469
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODEA015659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist