Provider Demographics
NPI:1942380480
Name:CATHEY, DERAN (DDS)
Entity Type:Individual
Prefix:
First Name:DERAN
Middle Name:
Last Name:CATHEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 W SERVICE DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-3822
Mailing Address - Country:US
Mailing Address - Phone:662-622-5500
Mailing Address - Fax:662-622-0004
Practice Address - Street 1:663 W SERVICE DR
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618-3822
Practice Address - Country:US
Practice Address - Phone:662-622-5500
Practice Address - Fax:662-622-0004
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2795-941223G0001X
DC53591223G0001X
MD95991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660094Medicaid