Healthcare Provider Details

I. General information

NPI: 1124227228
Provider Name (Legal Business Name): CARL THOMAS DRAKE D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SUSAN DR STE 1
NORMAL IL
61761-6206
US

IV. Provider business mailing address

310 SUSAN DRIVE, SUITE 1
NORMAL IL
61761
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-0054
  • Fax:
Mailing address:
  • Phone: 309-808-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.027428
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.002368
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: