Healthcare Provider Details

I. General information

NPI: 1730404187
Provider Name (Legal Business Name): JAMES R. DEATHERAGE D.M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 DOUGLAS AVE
BREWTON AL
36426-2052
US

IV. Provider business mailing address

422 DOUGLAS AVE
BREWTON AL
36426-2052
US

V. Phone/Fax

Practice location:
  • Phone: 251-867-6837
  • Fax: 251-867-6278
Mailing address:
  • Phone: 251-867-6837
  • Fax: 251-867-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4913
License Number StateAL

VIII. Authorized Official

Name: MRS. BECKY JANE BARROW
Title or Position: OFFICE MANAGER
Credential:
Phone: 251-867-6837