Provider Demographics
NPI:1760791545
Name:DEDEAUX, ANDREA SUE (RDH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUE
Last Name:DEDEAUX
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24036 E DUBUISSON RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-9073
Mailing Address - Country:US
Mailing Address - Phone:228-224-5930
Mailing Address - Fax:
Practice Address - Street 1:24036 E DUBUISSON RD
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-9073
Practice Address - Country:US
Practice Address - Phone:228-224-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3585-06DH124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist