Provider Demographics
NPI:1295881795
Name:ETHEREDGE, TROY KENDRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:TROY
Middle Name:KENDRICK
Last Name:ETHEREDGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:T
Other - Middle Name:KEN
Other - Last Name:ETHEREDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:205 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-8200
Mailing Address - Country:US
Mailing Address - Phone:432-349-1295
Mailing Address - Fax:
Practice Address - Street 1:2100 FM 1431
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4704
Practice Address - Country:US
Practice Address - Phone:830-693-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130791223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist