Provider Demographics
NPI:1053326157
Name:TEDFORD, SAMUEL KEITH (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:KEITH
Last Name:TEDFORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:S
Other - Middle Name:KEITH
Other - Last Name:TEDFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:8787 STREAMSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-9472
Mailing Address - Country:US
Mailing Address - Phone:423-238-5660
Mailing Address - Fax:423-472-6849
Practice Address - Street 1:115 INTERSTATE DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2642
Practice Address - Country:US
Practice Address - Phone:423-479-6005
Practice Address - Fax:423-472-6849
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice