Provider Demographics
NPI:1700422995
Name:DEDDEN, SAMUEL JACOB
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
Last Name:DEDDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4842 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-9132
Mailing Address - Country:US
Mailing Address - Phone:859-803-7696
Mailing Address - Fax:
Practice Address - Street 1:560 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3405
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant