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General NPI Number Information
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NPI Number | 1730404187
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Entity Type | Organization
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Legal Business Name | JAMES R. DEATHERAGE D.M.D.,P.C.
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Dates
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Enumeration Date | 03/29/2010
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Last Update Date | 03/29/2010
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Provider Practice Location Address
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Address Line | 422 DOUGLAS AVE
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City | BREWTON
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State | AL
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Zip | 36426-2052
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Country | US
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Telephone | 251-867-6837
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Fax | 251-867-6278
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Provider Business Mailing Address
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Address Line | 422 DOUGLAS AVE
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City | BREWTON
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State | AL
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Zip | 36426-2052
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Country | US
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Telephone | 251-867-6837
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Fax | 251-867-6278
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BECKY JANE BARROW
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Credential |
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Telephone | 251-867-6837
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4913
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License Number State | AL
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