Provider Demographics
NPI:1265543797
Name:DEATHERAGE, JAMES RANDALL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:DEATHERAGE
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 1:422 DOUGLAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426
Mailing Address - Country:US
Mailing Address - Phone:251-867-6837
Mailing Address - Fax:251-867-6278
Practice Address - Street 1:422 DOUGLAS AVENUE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426
Practice Address - Country:US
Practice Address - Phone:251-867-6837
Practice Address - Fax:251-867-6278
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist