Healthcare Provider Details

I. General information

NPI: 1902033061
Provider Name (Legal Business Name): RONNIE DRAKE DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 BIDDLE ST
SAINT LOUIS MO
63106-3454
US

IV. Provider business mailing address

1717 BIDDLE ST
SAINT LOUIS MO
63106-3454
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8581
  • Fax: 314-814-8542
Mailing address:
  • Phone: 314-814-8582
  • Fax: 341-814-8542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number013374
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: